[Congressional Record (Bound Edition), Volume 155 (2009), Part 20]
[House]
[Pages 27213-27575]
[From the U.S. Government Publishing Office, www.gpo.gov]




                 AFFORDABLE HEALTH CARE FOR AMERICA ACT

  Mr. WAXMAN. Mr. Speaker, pursuant to House Resolution 903, I call up 
the bill (H.R. 3962) to provide affordable, quality health care for all 
Americans and reduce the growth in health care spending, and for other 
purposes, and ask for its immediate consideration in the House.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
amendment printed in part A of House Report 111-330, perfected by the 
modification printed in part B of the report is adopted and the bill, 
as amended, is considered read.
  The text of the bill, as amended, is as follows:

                               H.R. 3962

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

[[Page 27214]]



     SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND 
                   SUBTITLES.

       (a) Short Title.--This Act may be cited as the ``Affordable 
     Health Care for America Act''.
       (b) Table of Divisions, Titles, and Subtitles.--This Act is 
     divided into divisions, titles, and subtitles as follows:

               DIVISION A--AFFORDABLE HEALTH CARE CHOICES

TITLE I--IMMEDIATE REFORMS
TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Subtitle D--Additional Consumer Protections
Subtitle E--Governance
Subtitle F--Relation to Other Requirements; Miscellaneous
TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Subtitle B--Public Health Insurance Option
Subtitle C--Individual Affordability Credits
TITLE IV--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Subtitle B--Employer Responsibility
TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Subtitle C--Disclosures To Carry Out Health Insurance Exchange 
              Subsidies
Subtitle D--Other Revenue Provisions

             DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions related to Medicare part A
Subtitle B--Provisions Related to Part B
Subtitle C--Provisions Related to Medicare Parts A and B
Subtitle D--Medicare Advantage Reforms
Subtitle E--Improvements to Medicare Part D
Subtitle F--Medicare Rural Access Protections
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low 
              Income Medicare Beneficiaries
Subtitle B--Reducing Health Disparities
Subtitle C--Miscellaneous Improvements
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND 
              COORDINATED CARE
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Subtitle B--Nursing Home Transparency
Subtitle C--Quality Measurements
Subtitle D--Physician Payments Sunshine Provision
Subtitle E--Public Reporting on Health Care-Associated Infections
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased funding to fight waste, fraud, and abuse
Subtitle B--Enhanced penalties for fraud and abuse
Subtitle C--Enhanced Program and Provider Protections
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and 
              Abuse
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
Subtitle B--Prevention
Subtitle C--Access
Subtitle D--Coverage
Subtitle E--Financing
Subtitle F--Waste, Fraud, and Abuse
Subtitle G--Puerto Rico and the Territories
Subtitle H--Miscellaneous
TITLE VIII--REVENUE-RELATED PROVISIONS
TITLE IX--MISCELLANEOUS PROVISIONS

          DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERS
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Subtitle B--Nursing Workforce
Subtitle C--Public Health Workforce
Subtitle D--Adapting Workforce to Evolving Health System Needs
TITLE III--PREVENTION AND WELLNESS
TITLE IV--QUALITY AND SURVEILLANCE
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program 
              Integrity
Subtitle B--Programs
Subtitle C--Food and Drug Administration
Subtitle D--Community Living Assistance Services and Supports
Subtitle E--Miscellaneous

               DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

TITLE I--AMENDMENTS TO INDIAN LAWS
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL 
              SECURITY ACT

               DIVISION A--AFFORDABLE HEALTH CARE CHOICES

     SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL 
                   DEFINITIONS.

       (a) Purpose.--
       (1) In general.--The purpose of this division is to provide 
     affordable, quality health care for all Americans and reduce 
     the growth in health care spending.
       (2) Building on current system.--This division achieves 
     this purpose by building on what works in today's health care 
     system, while repairing the aspects that are broken.
       (3) Insurance reforms.--This division--
       (A) enacts strong insurance market reforms;
       (B) creates a new Health Insurance Exchange, with a public 
     health insurance option alongside private plans;
       (C) includes sliding scale affordability credits; and
       (D) initiates shared responsibility among workers, 
     employers, and the Government;
     so that all Americans have coverage of essential health 
     benefits.
       (4) Health delivery reform.--This division institutes 
     health delivery system reforms both to increase quality and 
     to reduce growth in health spending so that health care 
     becomes more affordable for businesses, families, and 
     Government.
       (b) Table of Contents of Division.--The table of contents 
     of this division is as follows:

Sec. 100. Purpose; table of contents of division; general definitions.

                       TITLE I--IMMEDIATE REFORMS

Sec. 101. National high-risk pool program.
Sec. 102. Ensuring value and lower premiums.
Sec. 103. Ending health insurance rescission abuse.
Sec. 104. Sunshine on price gouging by health insurance issuers.
Sec. 105. Requiring the option of extension of dependent coverage for 
              uninsured young adults.
Sec. 106. Limitations on preexisting condition exclusions in group 
              health plans in advance of applicability of new 
              prohibition of preexisting condition exclusions.
Sec. 107. Prohibiting acts of domestic violence from being treated as 
              preexisting conditions.
Sec. 108. Ending health insurance denials and delays of necessary 
              treatment for children with deformities.
Sec. 109. Elimination of lifetime limits.
Sec. 110. Prohibition against postretirement reductions of retiree 
              health benefits by group health plans.
Sec. 111. Reinsurance program for retirees.
Sec. 112. Wellness program grants.
Sec. 113. Extension of COBRA continuation coverage.
Sec. 114. State Health Access Program grants.
Sec. 115. Administrative simplification.

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

                     Subtitle A--General Standards

Sec. 201. Requirements reforming health insurance marketplace.
Sec. 202. Protecting the choice to keep current coverage.

    Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 211. Prohibiting preexisting condition exclusions.
Sec. 212. Guaranteed issue and renewal for insured plans and 
              prohibiting rescissions.
Sec. 213. Insurance rating rules.
Sec. 214. Nondiscrimination in benefits; parity in mental health and 
              substance abuse disorder benefits.
Sec. 215. Ensuring adequacy of provider networks.
Sec. 216. Requiring the option of extension of dependent coverage for 
              uninsured young adults.
Sec. 217. Consistency of costs and coverage under qualified health 
              benefits plans during plan year.

    Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 221. Coverage of essential benefits package.
Sec. 222. Essential benefits package defined.
Sec. 223. Health Benefits Advisory Committee.
Sec. 224. Process for adoption of recommendations; adoption of benefit 
              standards.

              Subtitle D--Additional Consumer Protections

Sec. 231. Requiring fair marketing practices by health insurers.
Sec. 232. Requiring fair grievance and appeals mechanisms.
Sec. 233. Requiring information transparency and plan disclosure.
Sec. 234. Application to qualified health benefits plans not offered 
              through the Health Insurance Exchange.
Sec. 235. Timely payment of claims.
Sec. 236. Standardized rules for coordination and subrogation of 
              benefits.
Sec. 237. Application of administrative simplification.

[[Page 27215]]

Sec. 238. State prohibitions on discrimination against health care 
              providers.
Sec. 239. Protection of physician prescriber information.
Sec. 240. Dissemination of advance care planning information.

                         Subtitle E--Governance

Sec. 241. Health Choices Administration; Health Choices Commissioner.
Sec. 242. Duties and authority of Commissioner.
Sec. 243. Consultation and coordination.
Sec. 244. Health Insurance Ombudsman.

       Subtitle F--Relation to Other Requirements; Miscellaneous

Sec. 251. Relation to other requirements.
Sec. 252. Prohibiting discrimination in health care.
Sec. 253. Whistleblower protection.
Sec. 254. Construction regarding collective bargaining.
Sec. 255. Severability.
Sec. 256. Treatment of Hawaii Prepaid Health Care Act.
Sec. 257. Actions by State attorneys general.
Sec. 258. Application of State and Federal laws regarding abortion.
Sec. 259. Nondiscrimination on abortion and respect for rights of 
              conscience.
Sec. 260. Authority of Federal Trade Commission.
Sec. 261. Construction regarding standard of care.
Sec. 262. Restoring application of antitrust laws to health sector 
              insurers.
Sec. 263. Study and report on methods to increase EHR use by small 
              health care providers.
Sec. 264. Performance Assessment and Accountability; Application of 
              GPRA

      TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

                 Subtitle A--Health Insurance Exchange

Sec. 301. Establishment of Health Insurance Exchange; outline of 
              duties; definitions.
Sec. 302. Exchange-eligible individuals and employers.
Sec. 303. Benefits package levels.
Sec. 304. Contracts for the offering of Exchange-participating health 
              benefits plans.
Sec. 305. Outreach and enrollment of Exchange-eligible individuals and 
              employers in Exchange-participating health benefits plan.
Sec. 306. Other functions.
Sec. 307. Health Insurance Exchange Trust Fund.
Sec. 308. Optional operation of State-based health insurance exchanges.
Sec. 309. Interstate health insurance compacts.
Sec. 310. Health insurance cooperatives.
Sec. 311. Retention of DOD and VA authority.

               Subtitle B--Public Health Insurance Option

Sec. 321. Establishment and administration of a public health insurance 
              option as an Exchange-qualified health benefits plan.
Sec. 322. Premiums and financing.
Sec. 323. Payment rates for items and services.
Sec. 324. Modernized payment initiatives and delivery system reform.
Sec. 325. Provider participation.
Sec. 326. Application of fraud and abuse provisions.
Sec. 327. Application of HIPAA insurance requirements.
Sec. 328. Application of health information privacy, security, and 
              electronic transaction requirements.
Sec. 329. Enrollment in public health insurance option is voluntary.
Sec. 330. Enrollment in public health insurance option by Members of 
              Congress.
Sec. 331. Reimbursement of Secretary of Veterans Affairs.

              Subtitle C--Individual Affordability Credits

Sec. 341. Availability through Health Insurance Exchange.
Sec. 342. Affordable credit eligible individual.
Sec. 343. Affordability premium credit.
Sec. 344. Affordability cost-sharing credit.
Sec. 345. Income determinations.
Sec. 346. Special rules for application to territories.
Sec. 347. No Federal payment for undocumented aliens.

                    TITLE IV--SHARED RESPONSIBILITY

                 Subtitle A--Individual Responsibility

Sec. 401. Individual responsibility.

                  Subtitle B--Employer Responsibility

           Part 1--Health Coverage Participation Requirements

Sec. 411. Health coverage participation requirements.
Sec. 412. Employer responsibility to contribute toward employee and 
              dependent coverage.
Sec. 413. Employer contributions in lieu of coverage.
Sec. 414. Authority related to improper steering.
Sec. 415. Impact study on employer responsibility requirements.
Sec. 416. Study on employer hardship exemption.

   Part 2--Satisfaction of Health Coverage Participation Requirements

Sec. 421. Satisfaction of health coverage participation requirements 
              under the Employee Retirement Income Security Act of 
              1974.
Sec. 422. Satisfaction of health coverage participation requirements 
              under the Internal Revenue Code of 1986.
Sec. 423. Satisfaction of health coverage participation requirements 
              under the Public Health Service Act.
Sec. 424. Additional rules relating to health coverage participation 
              requirements.

          TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

         Subtitle A--Provisions Relating to Health Care Reform

                     Part 1--Shared Responsibility

                  subpart a--individual responsibility

Sec. 501. Tax on individuals without acceptable health care coverage.

                   subpart b--employer responsibility

Sec. 511. Election to satisfy health coverage participation 
              requirements.
Sec. 512. Health care contributions of nonelecting employers.

  Part 2--Credit for Small Business Employee Health Coverage Expenses

Sec. 521. Credit for small business employee health coverage expenses.

        Part 3--Limitations on Health Care Related Expenditures

Sec. 531. Distributions for medicine qualified only if for prescribed 
              drug or insulin.
Sec. 532. Limitation on health flexible spending arrangements under 
              cafeteria plans.
Sec. 533. Increase in penalty for nonqualified distributions from 
              health savings accounts.
Sec. 534. Denial of deduction for federal subsidies for prescription 
              drug plans which have been excluded from gross income.

     Part 4--Other Provisions to Carry Out Health Insurance Reform

Sec. 541. Disclosures to carry out health insurance exchange subsidies.
Sec. 542. Offering of exchange-participating health benefits plans 
              through cafeteria plans.
Sec. 543. Exclusion from gross income of payments made under 
              reinsurance program for retirees.
Sec. 544. CLASS program treated in same manner as long-term care 
              insurance.
Sec. 545. Exclusion from gross income for medical care provided for 
              Indians.

                  Subtitle B--Other Revenue Provisions

                       Part 1--General Provisions

Sec. 551. Surcharge on high income individuals.
Sec. 552. Excise tax on medical devices.
Sec. 553. Expansion of information reporting requirements.
Sec. 554. Repeal of Worldwide Allocation of Interest.
Sec. 555. Exclusion of Unprocessed fuel from the Cellulosic Biofuel 
              Producer Credit.

                  Part 2--Prevention of Tax Avoidance

Sec. 561. Limitation on treaty benefits for certain deductible 
              payments.
Sec. 562. Codification of economic substance doctrine; penalties.
Sec. 563. Certain large or publicly traded persons made subject to a 
              more likely than not standard for avoiding penalties on 
              underpayments.

                   Part 3--Parity in Health Benefits

Sec. 571. Certain health related benefits applicable to spouses and 
              dependents extended to eligible beneficiaries.
       (c) General Definitions.--Except as otherwise provided, in 
     this division:
       (1) Acceptable coverage.--The term ``acceptable coverage'' 
     has the meaning given such term in section 302(d)(2).
       (2) Basic plan.--The term ``basic plan'' has the meaning 
     given such term in section 303(c).
       (3) Commissioner.--The term ``Commissioner'' means the 
     Health Choices Commissioner established under section 241.
       (4) Cost-sharing.--The term ``cost-sharing'' includes 
     deductibles, coinsurance, copayments, and similar charges, 
     but does not include premiums, balance billing amounts for 
     non-network providers, or spending for non-covered services.
       (5) Dependent.--The term ``dependent'' has the meaning 
     given such term by the Commissioner and includes a spouse.
       (6) Employment-based health plan.--The term ``employment-
     based health plan''--
       (A) means a group health plan (as defined in section 
     733(a)(1) of the Employee Retirement Income Security Act of 
     1974);
       (B) includes such a plan that is the following:
       (i) Federal, state, and tribal governmental plans.--A 
     governmental plan (as defined in section 3(32) of the 
     Employee Retirement Income Security Act of 1974), including

[[Page 27216]]

     a health benefits plan offered under chapter 89 of title 5, 
     United States Code.
       (ii) Church plans.--A church plan (as defined in section 
     3(33) of the Employee Retirement Income Security Act of 
     1974); and
       (C) excludes coverage described in section 302(d)(2)(E) 
     (relating to TRICARE).
       (7) Enhanced plan.--The term ``enhanced plan'' has the 
     meaning given such term in section 303(c).
       (8) Essential benefits package.--The term ``essential 
     benefits package'' is defined in section 222(a).
       (9) Exchange-participating health benefits plan.--The term 
     ``Exchange-participating health benefits plan'' means a 
     qualified health benefits plan that is offered through the 
     Health Insurance Exchange and may be purchased directly from 
     the entity offering the plan or through enrollment agents and 
     brokers.
       (10) Family.--The term ``family'' means an individual and 
     includes the individual's dependents.
       (11) Federal poverty level; fpl.--The terms ``Federal 
     poverty level'' and ``FPL'' have the meaning given the term 
     ``poverty line'' in section 673(2) of the Community Services 
     Block Grant Act (42 U.S.C. 9902(2)), including any revision 
     required by such section.
       (12) Health benefits plan.--The term ``health benefits 
     plan'' means health insurance coverage and an employment-
     based health plan and includes the public health insurance 
     option.
       (13) Health insurance coverage.--The term ``health 
     insurance coverage'' has the meaning given such term in 
     section 2791 of the Public Health Service Act, but does not 
     include coverage in relation to its provision of excepted 
     benefits--
       (A) described in paragraph (1) of subsection (c) of such 
     section; or
       (B) described in paragraph (2), (3), or (4) of such 
     subsection if the benefits are provided under a separate 
     policy, certificate, or contract of insurance.
       (14) Health insurance issuer.--The term ``health insurance 
     issuer'' has the meaning given such term in section 
     2791(b)(2) of the Public Health Service Act.
       (15) Health insurance exchange.--The term ``Health 
     Insurance Exchange'' means the Health Insurance Exchange 
     established under section 301.
       (16) Indian.--The term ``Indian'' has the meaning given 
     such term in section 4 of the Indian Health Care Improvement 
     Act (24 U.S.C. 1603).
       (17) Indian health care provider.--The term ``Indian health 
     care provider'' means a health care program operated by the 
     Indian Health Service, an Indian tribe, tribal organization, 
     or urban Indian organization as such terms are defined in 
     section 4 of the Indian Health Care Improvement Act (25 
     U.S.C. 1603).
       (18) Medicaid.--The term ``Medicaid'' means a State plan 
     under title XIX of the Social Security Act (whether or not 
     the plan is operating under a waiver under section 1115 of 
     such Act).
       (19) Medicaid eligible individual.--The term ``Medicaid 
     eligible individual'' means an individual who is eligible for 
     medical assistance under Medicaid.
       (20) Medicare.--The term ``Medicare'' means the health 
     insurance programs under title XVIII of the Social Security 
     Act.
       (21) Plan sponsor.--The term ``plan sponsor'' has the 
     meaning given such term in section 3(16)(B) of the Employee 
     Retirement Income Security Act of 1974.
       (22) Plan year.--The term ``plan year'' means--
       (A) with respect to an employment-based health plan, a plan 
     year as specified under such plan; or
       (B) with respect to a health benefits plan other than an 
     employment-based health plan, a 12-month period as specified 
     by the Commissioner.
       (23) Premium plan; premium-plus plan.--The terms ``premium 
     plan'' and ``premium-plus plan'' have the meanings given such 
     terms in section 303(c).
       (24) QHBP offering entity.--The terms ``QHBP offering 
     entity'' means, with respect to a health benefits plan that 
     is--
       (A) a group health plan (as defined, subject to subsection 
     (d), in section 733(a)(1) of the Employee Retirement Income 
     Security Act of 1974), the plan sponsor in relation to such 
     group health plan, except that, in the case of a plan 
     maintained jointly by 1 or more employers and 1 or more 
     employee organizations and with respect to which an employer 
     is the primary source of financing, such term means such 
     employer;
       (B) health insurance coverage, the health insurance issuer 
     offering the coverage;
       (C) the public health insurance option, the Secretary of 
     Health and Human Services;
       (D) a non-Federal governmental plan (as defined in section 
     2791(d) of the Public Health Service Act), the State or 
     political subdivision of a State (or agency or 
     instrumentality of such State or subdivision) which 
     establishes or maintains such plan; or
       (E) a Federal governmental plan (as defined in section 
     2791(d) of the Public Health Service Act), the appropriate 
     Federal official.
       (25) Qualified health benefits plan.--The term ``qualified 
     health benefits plan'' means a health benefits plan that--
       (A) meets the requirements for such a plan under title II 
     and includes the public health insurance option; and
       (B) is offered by a QHBP offering entity that meets the 
     applicable requirements of such title with respect to such 
     plan.
       (26) Public health insurance option.--The term ``public 
     health insurance option'' means the public health insurance 
     option as provided under subtitle B of title III.
       (27) Service area; premium rating area.--The terms 
     ``service area'' and ``premium rating area'' mean with 
     respect to health insurance coverage--
       (A) offered other than through the Health Insurance 
     Exchange, such an area as established by the QHBP offering 
     entity of such coverage in accordance with applicable State 
     law; and
       (B) offered through the Health Insurance Exchange, such an 
     area as established by such entity in accordance with 
     applicable State law and applicable rules of the Commissioner 
     for Exchange-participating health benefits plans.
       (28) State.--The term ``State'' means the 50 States and the 
     District of Columbia and includes--
       (A) for purposes of title I, Puerto Rico, the Virgin 
     Islands, Guam, American Samoa, and the Northern Mariana 
     Islands; and
       (B) for purposes of titles II and III, as elected under and 
     subject to section 346, Puerto Rico, the Virgin Islands, 
     Guam, American Samoa, and the Northern Mariana Islands.
       (29) State medicaid agency.--The term ``State Medicaid 
     agency'' means, with respect to a Medicaid plan, the single 
     State agency responsible for administering such plan under 
     title XIX of the Social Security Act.
       (30) Y1, y2, etc.--The terms ``Y1'', ``Y2'', ``Y3'', 
     ``Y4'', ``Y5'', and similar subsequently numbered terms, mean 
     2013 and subsequent years, respectively.

                       TITLE I--IMMEDIATE REFORMS

     SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish a temporary national high-risk pool program (in 
     this section referred to as the ``program'') to provide 
     health benefits to eligible individuals during the period 
     beginning on January 1, 2010, and, subject to subsection 
     (h)(3)(B), ending on the date on which the Health Insurance 
     Exchange is established.
       (b) Administration.--The Secretary may carry out this 
     section directly or, pursuant to agreements, grants, or 
     contracts with States, through State high-risk pool programs 
     provided that the requirements of this section are met. ``For 
     a State without a high-risk pool program, the Secretary may 
     work with the State to coordinate with other forms of 
     coverage expansions, such as State public-private 
     partnerships.''.
       (c) Eligibility.--For purposes of this section, the term 
     ``eligible individual'' means an individual ``who meets the 
     requirements of subsection (i)(1)''.
       (1) who--
       (A) is not eligible for--
       (i) benefits under title XVIII, XIX, or XXI of the Social 
     Security Act; or
       (ii) coverage under an employment-based health plan (not 
     including coverage under a COBRA continuation provision, as 
     defined in section 107(d)(1)); and
       (B) who--
       (i) is an eligible individual under section 2741(b) of the 
     Public Health Service Act; or
       (ii) is medically eligible for the program by virtue of 
     being an individual described in subsection (d) at any time 
     during the 6-month period ending on the date the individual 
     applies for high-risk pool coverage under this section;
       (2) who is the spouse or dependent of an individual who is 
     described in paragraph (1);
       (3) who has not had health insurance coverage or coverage 
     under an employment-based health plan for at least the 6-
     month period immediately preceding the date of the 
     individual's application for high-risk pool coverage under 
     this section; ``or.''
       (4) who on or after October 29, 2009, had employment-based 
     retiree health coverage (as defined in subsection (i)) and 
     the annual increase in premiums for such individual under 
     such coverage (for any coverage period beginning on or after 
     such date) exceeds such excessive percentage as the Secretary 
     shall specify.
     For purposes of paragraph (1)(A)(ii), a person who is in a 
     waiting period as defined in section 2701(b)(4) of the Public 
     Health Service Act shall not be considered to be eligible for 
     coverage under an employment-based health plan.
       (d) Medically Eligible Requirements.--For purposes of 
     subsection (c)(1)(B)(ii), an individual described in this 
     subsection is an individual--
       (1) who, during the 6-month period ending on the date the 
     individual applies for high-risk pool coverage under this 
     section applied for individual health insurance coverage 
     and--
       (A) was denied such coverage because of a preexisting 
     condition or health status; or
       (B) was offered such coverage--
       (i) under terms that limit the coverage for such a 
     preexisting condition; or

[[Page 27217]]

       (ii) at a premium rate that is above the premium rate for 
     high risk pool coverage under this section; or
       (2) who has an eligible medical condition as defined by the 
     Secretary.
     In making a determination under paragraph (1) of whether an 
     individual was offered individual coverage at a premium rate 
     above the premium rate for high risk pool coverage, the 
     Secretary shall make adjustments to offset differences in 
     premium rating that are attributable solely to differences in 
     age rating.
       (e) Enrollment.--To enroll in coverage in the program, an 
     individual shall--
       (1) submit to the Secretary an application for 
     participation in the program, at such time, in such manner, 
     and containing such information as the Secretary shall 
     require;
       (2) attest ``, consistent with subsection (i)(2),'' that 
     the individual is an eligible individual and is a resident of 
     one of the 50 States or the District of Columbia; and
       (3) if the individual had other prior health insurance 
     coverage or coverage under an employment-based health plan 
     during the previous 6 months, provide information as to the 
     nature and source of such coverage and reasons for its 
     discontinuance.
       (f) Protection Against Dumping Risks by Insurers.--
       (1) In general.--The Secretary shall establish criteria for 
     determining whether health insurance issuers and employment-
     based health plans have discouraged an individual from 
     remaining enrolled in prior coverage based on that 
     individual's health status.
       (2) Sanctions.--An issuer or employment-based health plan 
     shall be responsible for reimbursing the program for the 
     medical expenses incurred by the program for an individual 
     who, based on criteria established by the Secretary, the 
     Secretary finds was encouraged by the issuer to disenroll 
     from health benefits coverage prior to enrolling in the 
     program. The criteria shall include at least the following 
     circumstances:
       (A) In the case of prior coverage obtained through an 
     employer, the provision by the employer, group health plan, 
     or the issuer of money or other financial consideration for 
     disenrolling from the coverage.
       (B) In the case of prior coverage obtained directly from an 
     issuer or under an employment-based health plan--
       (i) the provision by the issuer or plan of money or other 
     financial consideration for disenrolling from the coverage; 
     or
       (ii) in the case of an individual whose premium for the 
     prior coverage exceeded the premium required by the program 
     (adjusted based on the age factors applied to the prior 
     coverage)--

       (I) the prior coverage is a policy that is no longer being 
     actively marketed (as defined by the Secretary) by the 
     issuer; or
       (II) the prior coverage is a policy for which duration of 
     coverage form issue or health status are factors that can be 
     considered in determining premiums at renewal.

       (3) Construction.--Nothing in this subsection shall be 
     construed as constituting exclusive remedies for violations 
     of criteria established under paragraph (1) or as preventing 
     States from applying or enforcing such paragraph or other 
     provisions under law with respect to health insurance 
     issuers.
       (g) Covered Benefits, Cost-sharing, Premiums, and Consumer 
     Protections.--
       (1) Premium.--The monthly premium charged to eligible 
     individuals for coverage under the program--
       (A) may vary by age so long as the ratio of the highest 
     such premium to the lowest such premium does not exceed the 
     ratio of 2 to 1;
       (B) shall be set at a level that does not exceed 125 
     percent of the prevailing standard rate for comparable 
     coverage in the individual market; and
       (C) shall be adjusted for geographic variation in costs.
     Health insurance issuers shall provide such information as 
     the Secretary may require to determine prevailing standard 
     rates under this paragraph. The Secretary shall establish 
     standard rates in consultation with the National Association 
     of Insurance Commissioners.
       (2) Covered benefits.--Covered benefits under the program 
     shall be determined by the Secretary and shall be consistent 
     with the basic categories in the essential benefits package 
     described in section 222. Under such benefits package--
       (A) the annual deductible for such benefits may not be 
     higher than $1,500 for an individual or such higher amount 
     for a family as determined by the Secretary;
       (B) there may not be annual or lifetime limits; and
       (C) the maximum cost-sharing with respect to an individual 
     (or family) for a year shall not exceed $5,000 for an 
     individual (or $10,000 for a family).
       (3) No preexisting condition exclusion periods.--No 
     preexisting condition exclusion period shall be imposed on 
     coverage under the program.
       (4) Appeals.--The Secretary shall establish an appeals 
     process for individuals to appeal a determination of the 
     Secretary--
       (A) with respect to claims submitted under this section; 
     and
       (B) with respect to eligibility determinations made by the 
     Secretary under this section.
       (5) State contribution, maintenance of effort.--As a 
     condition of providing health benefits under this section to 
     eligible individual residing in a State--
       (A) in the case of a State in which a qualified high-risk 
     pool (as defined under section 2744(c)(2) of the Public 
     Health Service Act) was in effect as of July 1, 2009, the 
     Secretary shall require the State make a maintenance of 
     effort payment each year that the high-risk pool is in effect 
     equal to an amount not less than the amount of all sources of 
     funding for high-risk pool coverage made by that State in the 
     year ending July 1, 2009; and
       (B) in the case of a State which required health insurance 
     issuers to contribute to a State high-risk pool or similar 
     arrangement for the assessment against such issuers for pool 
     losses, the State shall maintain such a contribution 
     arrangement among such issuers.
       (6) Limiting program expenditures.--The Secretary shall, 
     with respect to the program--
       (A) establish procedures to protect against fraud, waste, 
     and abuse under the program; and
       (B) provide for other program integrity methods.
       (7) Treatment as creditable coverage.--Coverage under the 
     program shall be treated, for purposes of applying the 
     definition of ``creditable coverage'' under the provisions of 
     title XXVII of the Public Health Service Act, part 6 of 
     subtitle B of title I of Employee Retirement Income Security 
     Act of 1974, and chapter 100 of the Internal Revenue Code of 
     1986 (and any other provision of law that references such 
     provisions) in the same manner as if it were coverage under a 
     State health benefits risk pool described in section 
     2701(c)(1)(G) of the Public Health Service Act.
       (h) Funding; Termination of Authority.--
       (1) In general.--There is appropriated to the Secretary, 
     out of any moneys in the Treasury not otherwise appropriated, 
     $5,000,000,000 to pay claims against (and administrative 
     costs of) the high-risk pool under this section in excess of 
     the premiums collected with respect to eligible individuals 
     enrolled in the high-risk pool. Such funds shall be available 
     without fiscal year limitation.
       (2) Insufficient funds.--If the Secretary estimates for any 
     fiscal year that the aggregate amounts available for payment 
     of expenses of the high-risk pool will be less than the 
     amount of the expenses, the Secretary shall make such 
     adjustments as are necessary to eliminate such deficit, 
     including reducing benefits, increasing premiums, or 
     establishing waiting lists.
       (3) Termination of authority.--
       (A) In general.--Except as provided in subparagraph (B), 
     coverage of eligible individuals under a high-risk pool shall 
     terminate as of the date on which the Health Insurance 
     Exchange is established.
       (B) Transition to exchange.--The Secretary shall develop 
     procedures to provide for the transition of eligible 
     individuals who are enrolled in health insurance coverage 
     offered through a high-risk pool established under this 
     section to be enrolled in acceptable coverage. Such 
     procedures shall ensure that there is no lapse in coverage 
     with respect to the individual and may extend coverage 
     offered through such a high-risk pool beyond 2012 if the 
     Secretary determines necessary to avoid such a lapse.
       (i) Application and Verification of Requirement of 
     Citizenship or Lawful Presence in the United States.--
       (1) Requirement.--No individual shall be an eligible 
     individual under this section unless the individual is a 
     citizen or national of the United States or is lawfully 
     present in a State in the United States (other than as a 
     nonimmigrant described in a subparagraph (excluding 
     subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) 
     of the Immigration and Nationality Act.)
       (2) Application of verification process for affordability 
     credit.--The provisions of paragraphs (4) (other than 
     subparagraphs (F) and (H)(i)) and (5)(A) of section 341(b), 
     and of subsections (v) (other than paragraph (3)) and (x) of 
     section 205 of the Social Security Act, shall apply to the 
     verification of eligibility of an eligible individual by the 
     Secretary (or by a State agency approved by the Secretary) 
     for benefits under this section in the same manner as such 
     provisions apply to the verification of eligibility of a 
     affordable credit eligible individual for affordability 
     credits by the Commissioner under section 341(b). The 
     agreement referred to in section 205(v)(2)(A) of the Social 
     Security Act (as applied under this paragraph) shall also 
     provide for funding, to be payable for the amount made 
     available under subsection (h)(1), to the Commissioner of 
     Social Security in such amount as is agreed to by such 
     Commissioner and the Secretary.
       (j) Employment-based Retiree Health Coverage.--In this 
     section, the term ``employment-based retiree health 
     coverage'' means health insurance or other coverage of health 
     care costs (whether provided by voluntary insurance or 
     pursuant to statutory or contractual obligation) for 
     individuals (or for such individuals and their spouses and 
     dependents) under a group health plan based on their status 
     as retired participants in such plan.

[[Page 27218]]



     SEC. 102. ENSURING VALUE AND LOWER PREMIUMS.

       (a) Group Health Insurance Coverage.--Title XXVII of the 
     Public Health Service Act is amended by inserting after 
     section 2713 the following new section:

     ``SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

       ``(a) In General.--Each health insurance issuer that offers 
     health insurance coverage in the small or large group market 
     shall provide that for any plan year in which the coverage 
     has a medical loss ratio below a level specified by the 
     Secretary (but not less than 85 percent), the issuer shall 
     provide in a manner specified by the Secretary for rebates to 
     enrollees of the amount by which the issuer's medical loss 
     ratio is less than the level so specified.
       ``(b) Implementation.--The Secretary shall establish a 
     uniform definition of medical loss ratio and methodology for 
     determining how to calculate it based on the average medical 
     loss ratio in a health insurance issuer's book of business 
     for the small and large group market. Such methodology shall 
     be designed to take into account the special circumstances of 
     smaller plans, different types of plans, and newer plans. In 
     determining the medical loss ratio, the Secretary shall 
     exclude State taxes and licensing or regulatory fees. Such 
     methodology shall be designed and exceptions shall be 
     established to ensure adequate participation by health 
     insurance issuers, competition in the health insurance 
     market, and value for consumers so that their premiums are 
     used for services.
       ``(c) Sunset.--Subsections (a) and (b) shall not apply to 
     health insurance coverage on and after the first date that 
     health insurance coverage is offered through the Health 
     Insurance Exchange.''.
       (b) Individual Health Insurance Coverage.--Such title is 
     further amended by inserting after section 2753 the following 
     new section:

     ``SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

       ``The provisions of section 2714 shall apply to health 
     insurance coverage offered in the individual market in the 
     same manner as such provisions apply to health insurance 
     coverage offered in the small or large group market except to 
     the extent the Secretary determines that the application of 
     such section may destabilize the existing individual 
     market.''.
       (c) Immediate Implementation.--The amendments made by this 
     section shall apply in the group and individual market for 
     plan years beginning on or after January 1, 2010, or as soon 
     as practicable after such date.

     SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE.

       (a) Clarification Regarding Application of Guaranteed 
     Renewability of Individual and Group Health Insurance 
     Coverage.--Sections 2712 and 2742 of the Public Health 
     Service Act (42 U.S.C. 300gg-12, 300gg-42) are each amended--
       (1) in its heading, by inserting ``AND CONTINUATION IN 
     FORCE, INCLUDING PROHIBITION OF RESCISSION,'' after 
     ``GUARANTEED RENEWABILITY''; and
       (2) in subsection (a), by inserting ``, including without 
     rescission,'' after ``continue in force''.
       (b) Secretarial Guidance Regarding Rescissions.--
       (1) Group health insurance market.--Section 2712 of such 
     Act (42 U.S.C. 300gg-12) is amended by adding at the end the 
     following:
       ``(f) Rescission.--A health insurance issuer may rescind 
     group health insurance coverage only upon clear and 
     convincing evidence of fraud described in subsection (b)(2), 
     under procedures that provide for independent, external 
     third-party review.''.
       (2) Individual health market.--Section 2742 of such Act (42 
     U.S.C. 300gg-42) is amended by adding at the end the 
     following:
       ``(f) Rescission.--A health insurance issuer may rescind 
     individual health insurance coverage only upon clear and 
     convincing evidence of fraud described in subsection (b)(2), 
     under procedures that provide for independent, external 
     third-party review.''.
       (3) Guidance.--The Secretary of Health and Human Services, 
     no later than 90 days after the date of the enactment of this 
     Act, shall issue guidance implementing the amendments made by 
     paragraphs (1) and (2), including procedures for independent, 
     external third-party review.
       (c) Opportunity for Independent, External Third-party 
     Review in Certain Cases.--
       (1) Individual market.--Subpart 1 of part B of title XXVII 
     of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding 
     at the end the following:

     ``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-
                   PARTY REVIEW IN CASES OF RESCISSION.

       ``(a) Notice and Review Right.--If a health insurance 
     issuer determines to rescind health insurance coverage for an 
     individual in the individual market, before such rescission 
     may take effect the issuer shall provide the individual with 
     notice of such proposed rescission and an opportunity for a 
     review of such determination by an independent, external 
     third-party under procedures specified by the Secretary under 
     section 2742(f).
       ``(b) Independent Determination.--If the individual 
     requests such review by an independent, external third-party 
     of a rescission of health insurance coverage, the coverage 
     shall remain in effect until such third party determines that 
     the coverage may be rescinded under the guidance issued by 
     the Secretary under section 2742(f).''.
       (2) Application to group health insurance.--Such title is 
     further amended by adding after section 2702 the following 
     new section:

     ``SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-
                   PARTY REVIEW IN CASES OF RESCISSION.

       ``The provisions of section 2746 shall apply to group 
     health insurance coverage in the same manner as such 
     provisions apply to individual health insurance coverage, 
     except that any reference to section 2742(f) is deemed a 
     reference to section 2712(f).''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act 
     and shall apply to rescissions occurring on and after July 1, 
     2010, with respect to health insurance coverage issued 
     before, on, or after such date.

     SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE 
                   ISSUERS.

       (a) Initial Premium Review Process.--
       (1) In General.--The Secretary of Health and Human 
     Services, in conjunction with States, shall establish a 
     process for the annual review, beginning with 2010 and 
     subject to subsection (c)(3)(A), of increases in premiums for 
     health insurance coverage.
       (2) Justification and Disclosure.--Such process shall 
     require health insurance issuers to submit a justification 
     for any premium increase prior to implementation of the 
     increase. Such issuers shall prominently post such 
     information on their websites. The Secretary shall ensure the 
     public disclosure of information on such increase and 
     justifications for all health insurance issuers.
       (b) Continuing Premium Review Process.--
       (1) Informing commissioner of premium increase patterns.--
     As a condition of receiving a grant under subsection (c)(1), 
     a State, through its Commissioner of Insurance, shall--
       (A) provide the Health Choices commissioner with 
     information about trends in premium increases in health 
     insurance coverage in premium rating areas in the State; and
       (B) make recommendations, as appropriate, to such 
     Commissioner about whether particular health insurance 
     issuers should be excluded from participation in the Health 
     Insurance Exchange based on a pattern of excessive or 
     unjustified premium increases.
       (2) Commissioner authority regarding exchange 
     participation.--In making determinations concerning entering 
     into contracts with QHBP offering entities for the offering 
     of Exchange-participating health plans under section 304, the 
     Commissioner shall take into account the information and 
     recommendations provided under paragraph (1).
       (3) Monitoring by commissioner of premium increases.--
       (A) In general.--Beginning in 2014, the Commissioner, in 
     conjunction with the States and in place of the monitoring by 
     the Secretary under subsection (a)(1) and consistent with the 
     provisions of subsection (a)(2), shall monitor premium 
     increases of health insurance coverage offered inside the 
     Health Insurance Exchange under section 304 and outside of 
     the Exchange.
       (B) Consideration in opening exchange.--In determining 
     under section 302(e)(4) whether to make additional larger 
     employers eligible to participate in the Health Insurance 
     Exchange, the Commissioner shall take into account any excess 
     of premium growth outside the Exchange as compared to the 
     rate of such growth inside the Exchange, including 
     information reported by the States.
       (c) Grants in Support of Process.--
       (1) Premium review grants during 2010 through 2014.--The 
     Secretary shall carry out a program of grants to States 
     during the 5-year period beginning with 2010 to assist them 
     in carrying out subsection (a), including--
       (A) in reviewing and, if appropriate under State law, 
     approving premium increases for health insurance coverage; 
     and
       (B) in providing information and recommendations to the 
     Commissioner under subsection (b)(1).
       (2) Funding.--
       (A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary $1,000,000,000, to be available for expenditure for 
     grants under paragraph (1) and subparagraph (B).
       (B) Further availability for insurance reform and consumer 
     protection grants.--If the amounts appropriated under 
     subparagraph (A) are not fully obligated under grants under 
     paragraph (1) by the end of 2014, any remaining funds shall 
     remain available to the Secretary for grants to States for 
     planning and implementing the insurance reforms and consumer 
     protections under title II.
       (C) Allocation.--The Secretary shall establish a formula 
     for determining the amount of any grant to a State under this 
     subsection. Under such formula--

[[Page 27219]]

       (i) the Secretary shall consider the number of plans of 
     health insurance coverage offered in each State and the 
     population of the State; and
       (ii) no State qualifying for a grant under paragraph (1) 
     shall receive less than $1,000,000, or more than $5,000,000 
     for a grant year.

     SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       (a) Under Group Health Plans.--
       (1) PHSA.--Title XXVII of the Public Health Service Act is 
     amended by inserting after section 2702 the following new 
     section:

     ``SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering health insurance coverage in 
     connection with a group health plan that provides coverage 
     for dependent children shall make available such coverage, at 
     the option of the participant involved, for one or more 
     qualified children (as defined in subsection (b)) of the 
     participant.
       ``(b) Qualified Child Defined.--In this section, the term 
     `qualified child' means, with respect to a participant in a 
     group health plan or group health insurance coverage, an 
     individual who (but for age) would be treated as a dependent 
     child of the participant under such plan or coverage and 
     who--
       ``(1) is under 27 years of age; and
       ``(2) is not enrolled as a participant, beneficiary, or 
     enrollee (other than under this section, section 2746, or 
     section 704 of the Employee Retirement Income Security Act of 
     1974) under any health insurance coverage or group health 
     plan.
       ``(c) Premiums.--Nothing in this section shall be construed 
     as preventing a group health plan or health insurance issuer 
     with respect to group health insurance coverage from 
     increasing the premiums otherwise required for coverage 
     provided under this section consistent with standards 
     established by the Secretary based upon family size.''.
       (2) Employee retirement income security act of 1974.--
       (A) In general.--Part 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 is amended by 
     inserting after section 703 the following new section:

     ``SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering health insurance coverage in 
     connection with a group health plan that provides coverage 
     for dependent children shall make available such coverage, at 
     the option of the participant involved, for one or more 
     qualified children (as defined in subsection (b)) of the 
     participant.
       ``(b) Qualified Child Defined.--In this section, the term 
     `qualified child' means, with respect to a participant in a 
     group health plan or group health insurance coverage, an 
     individual who (but for age) would be treated as a dependent 
     child of the participant under such plan or coverage and 
     who--
       ``(1) is under 27 years of age; and
       ``(2) is not enrolled as a participant, beneficiary, or 
     enrollee (other than under this section) under any health 
     insurance coverage or group health plan.
       ``(c) Premiums.--Nothing in this section shall be construed 
     as preventing a group health plan or health insurance issuer 
     with respect to group health insurance coverage from 
     increasing the premiums otherwise required for coverage 
     provided under this section consistent with standards 
     established by the Secretary based upon family size.''.
       (B) Clerical amendment.--The table of contents of such Act 
     is amended by inserting after the item relating to section 
     703 the following new item:

``Sec. 704. Requiring the option of extension of dependent coverage for 
              uninsured young adults.''.
       (3) IRC.--
       (A) In general.--Subchapter A of chapter 100 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new section:

     ``SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       ``(a) In General.--A group health plan that provides 
     coverage for dependent children shall make available such 
     coverage, at the option of the participant involved, for one 
     or more qualified children (as defined in subsection (b)) of 
     the participant.
       ``(b) Qualified Child Defined.--In this section, the term 
     `qualified child' means, with respect to a participant in a 
     group health plan, an individual who (but for age) would be 
     treated as a dependent child of the participant under such 
     plan and who--
       ``(1) is under 27 years of age; and
       ``(2) is not enrolled as a participant, beneficiary, or 
     enrollee (other than under this section, section 704 of the 
     Employee Retirement Income Security Act of 1974, or section 
     2704 or 2746 of the Public Health Service Act) under any 
     health insurance coverage or group health plan.
       ``(c) Premiums.--Nothing in this section shall be construed 
     as preventing a group health plan from increasing the 
     premiums otherwise required for coverage provided under this 
     section consistent with standards established by the 
     Secretary based upon family size.''.
       (B) Clerical amendment.--The table of sections of such 
     chapter is amended by inserting after the item relating to 
     section 9803 the following:

``Sec. 9804. Requiring the option of extension of dependent coverage 
              for uninsured young adults.''.
       (b) Individual Health Insurance Coverage.--Title XXVII of 
     the Public Health Service Act is amended by inserting after 
     section 2745 the following new section:

     ``SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       ``The provisions of section 2703 shall apply to health 
     insurance coverage offered by a health insurance issuer in 
     the individual market in the same manner as they apply to 
     health insurance coverage offered by a health insurance 
     issuer in connection with a group health plan in the small or 
     large group market.''.
       (c) Effective Dates.--
       (1) Group health plans.--The amendments made by subsection 
     (a) shall apply to group health plans for plan years 
     beginning on or after January 1, 2010.
       (2) Individual health insurance coverage.--Section 2746 of 
     the Public Health Service Act, as inserted by subsection (b), 
     shall apply with respect to health insurance coverage 
     offered, sold, issued, renewed, in effect, or operated in the 
     individual market on or after January 1, 2010.

     SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN 
                   GROUP HEALTH PLANS IN ADVANCE OF APPLICABILITY 
                   OF NEW PROHIBITION OF PREEXISTING CONDITION 
                   EXCLUSIONS.

       (a) Amendments to the Employee Retirement Income Security 
     Act of 1974.--
       (1) Reduction in look-back period.--Section 701(a)(1) of 
     the Employee Retirement Income Security Act of 1974 (29 
     U.S.C. 1181(a)(1)) is amended by striking ``6-month period'' 
     and inserting ``30-day period''.
       (2) Reduction in permitted preexisting condition limitation 
     period.--Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2)) 
     is amended by striking ``12 months'' and inserting ``3 
     months'', and by striking ``18 months'' and inserting ``9 
     months''.
       (3) Sunset of interim limitation.--Section 701 of such Act 
     (29 U.S.C. 1181) is amended by adding at the end the 
     following new subsection:
       ``(h) Termination.--This section shall cease to apply to 
     any group health plan as of the date that such plan becomes 
     subject to the requirements of section 211 of the (relating 
     to prohibiting preexisting condition exclusions).''.
       (b) Amendments to the Internal Revenue Code of 1986.--
       (1) Reduction in look-back period.--Section 9801(a)(1) of 
     the Internal Revenue Code of 1986 is amended by striking ``6-
     month period'' and inserting ``30-day period''.
       (2) Reduction in permitted preexisting condition limitation 
     period.--Section 9801(a)(2) of such Code is amended by 
     striking ``12 months'' and inserting ``3 months'', and by 
     striking ``18 months'' and inserting ``9 months''.
       (3) Sunset of interim limitation.--Section 9801 of such 
     Code is amended by adding at the end the following new 
     subsection:
       ``(g) Termination.--This section shall cease to apply to 
     any group health plan as of the date that such plan becomes 
     subject to the requirements of section 211 of the 
     ``Affordable Health Care for America Act'' (relating to 
     prohibiting preexisting condition exclusions).''.
       (c) Amendments to Public Health Service Act.--
       (1) Reduction in look-back period.--Section 2701(a)(1) of 
     the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is 
     amended by striking ``6-month period'' and inserting ``30-day 
     period''.
       (2) Reduction in permitted preexisting condition limitation 
     period.--Section 2701(a)(2) of such Act (42 U.S.C. 
     300gg(a)(2)) is amended by striking ``12 months'' and 
     inserting ``3 months'', and by striking ``18 months'' and 
     inserting ``9 months''.
       (3) Sunset of interim limitation.--Section 2701 of such Act 
     (42 U.S.C. 300gg) is amended by adding at the end the 
     following new subsection:
       ``(h) Termination.--This section shall cease to apply to 
     any group health plan as of the date that such plan becomes 
     subject to the requirements of section 211 of the (relating 
     to prohibiting preexisting condition exclusions).''.
       (4) Miscellaneous technical amendment.--Section 2702(a)(2) 
     of such Act (42 U.S.C. 300gg-1) is amended by striking 
     ``701'' and inserting ``2701''.
       (d) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by this section shall apply with respect to 
     group health plans for plan years beginning on or after 
     January 1, 2010.
       (2) Special rule for collective bargaining agreements.--In 
     the case of a group health plan maintained pursuant to 1 or 
     more collective bargaining agreements between employee 
     representatives and 1 or more employers ratified before the 
     date of the enactment of this Act, the amendments made by 
     this section shall not apply to plan years beginning before 
     the earlier of--

[[Page 27220]]

       (A) the date on which the last of the collective bargaining 
     agreements relating to the plan terminates (determined 
     without regard to any extension thereof agreed to after the 
     date of the enactment of this Act);
       (B) 3 years after the date of the enactment of this Act.

     SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING 
                   TREATED AS PREEXISTING CONDITIONS.

       (a) ERISA.--Section 701(d)(3) of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. ) is amended--
       (1) in the heading, by inserting ``or domestic violence'' 
     after ``pregnancy''; and
       (2) by inserting ``or domestic violence'' after ``relating 
     to pregnancy''.
       (b) PHSA.--
       (1) Group market.--Section 2701(d)(3) of the Public Health 
     Service Act (42 U.S.C. 300gg(d)(3)) is amended--
       (A) in the heading, by inserting ``or domestic violence'' 
     after ``pregnancy''; and
       (B) by inserting ``or domestic violence'' after ``relating 
     to pregnancy''.
       (2) Individual market.--Title XXVII of such Act is amended 
     by inserting after section 2753 the following new section:

     ``SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PREEXISTING 
                   CONDITION.

       ``A health insurance issuer offering health insurance 
     coverage in the individual market may not, on the basis of 
     domestic violence, impose any preexisting condition exclusion 
     (as defined in section 2701(b)(1)(A)) with respect to such 
     coverage.''.
       (c) IRC.--Section 9801(d)(3) of the Internal Revenue Code 
     of 1986 is amended--
       (1) in the heading, by inserting ``or domestic violence'' 
     after ``pregnancy''; and
       (2) by inserting ``or domestic violence'' after ``relating 
     to pregnancy''.
       (d) Effective Dates.--
       (1) Except as otherwise provided in this subsection, the 
     amendments made by this section shall apply with respect to 
     group health plans (and health insurance issuers offering 
     group health insurance coverage) for plan years beginning on 
     or after January 1, 2010.
       (2) The amendment made by subsection (b)(2) shall apply 
     with respect to health insurance coverage offered, sold, 
     issued, renewed, in effect, or operated in the individual 
     market on or after such date.

     SEC. 108. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF 
                   NECESSARY TREATMENT FOR CHILDREN WITH 
                   DEFORMITIES.

       (a) Amendments to the Employee Retirement Income Security 
     Act of 1974.--
       (1) In general.--Subpart B of part 7 of subtitle B of title 
     I of the Employee Retirement Income Security Act of 1974 is 
     amended by adding at the end the following new section:

     ``SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
                   CONGENITAL OR DEVELOPMENTAL DEFORMITY OR 
                   DISORDER.

       ``(a) Requirements for Treatment for Children With 
     Deformities.--
       ``(1) In general.--A group health plan, and a health 
     insurance issuer offering group health insurance coverage, 
     that provides coverage for surgical benefits shall provide 
     coverage for outpatient and inpatient diagnosis and treatment 
     of a minor child's congenital or developmental deformity, 
     disease, or injury. A minor child shall include any 
     individual who is 21 years of age or younger.
       ``(2) Treatment defined.--
       ``(A) In general.--In this section, the term `treatment' 
     includes reconstructive surgical procedures (procedures that 
     are generally performed to improve function, but may also be 
     performed to approximate a normal appearance) that are 
     performed on abnormal structures of the body caused by 
     congenital defects, developmental abnormalities, trauma, 
     infection, tumors, or disease, including--
       ``(i) procedures that do not materially affect the function 
     of the body part being treated; and
       ``(ii) procedures for secondary conditions and follow-up 
     treatment.
       ``(B) Exception.--Such term does not include cosmetic 
     surgery performed to reshape normal structures of the body to 
     improve appearance or self-esteem.
       ``(b) Notice.--A group health plan under this part shall 
     comply with the notice requirement under section 713(b) 
     (other than paragraph (3)) with respect to the requirements 
     of this section.''.
       (2) Conforming amendment.--
       (A) Subsection (c) of section 731 of such Act is amended by 
     striking ``section 711'' and inserting ``sections 711 and 
     715''.
       (B) The table of contents in section 1 of such Act is 
     amended by inserting after the item relating to section 714 
     the following new item:

``Sec. 715. Standards relating to benefits for minor child's congenital 
              or developmental deformity or disorder.''.
       (b) Amendments to the Internal Revenue Code of 1986.--
       (1) In general.--Subchapter B of chapter 100 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new section:

     ``SEC. 9814. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
                   CONGENITAL OR DEVELOPMENTAL DEFORMITY OR 
                   DISORDER.

       ``(a) Requirements for Treatment for Children With 
     Deformities.--A group health plan that provides coverage for 
     surgical benefits shall provide coverage for outpatient and 
     inpatient diagnosis and treatment of a minor child's 
     congenital or developmental deformity, disease, or injury. A 
     minor child shall include any individual who is 21 years of 
     age or younger.
       ``(b) Treatment Defined.--
       ``(1) In general.--In this section, the term `treatment' 
     includes reconstructive surgical procedures (procedures that 
     are generally performed to improve function, but may also be 
     performed to approximate a normal appearance) that are 
     performed on abnormal structures of the body caused by 
     congenital defects, developmental abnormalities, trauma, 
     infection, tumors, or disease, including--
       ``(A) procedures that do not materially affect the function 
     of the body part being treated, and
       ``(B) procedures for secondary conditions and follow-up 
     treatment.
       ``(2) Exception.--Such term does not include cosmetic 
     surgery performed to reshape normal structures of the body to 
     improve appearance or self-esteem.''.
       (2) Clerical amendment.--The table of sections for 
     subchapter B of chapter 100 of such Code is amended by adding 
     at the end the following new item:

``Sec. 9814. Standards relating to benefits for minor child's 
              congenital or developmental deformity or disorder.''.
       (c) Amendments to the Public Health Service Act.--
       (1) In general.--Subpart 2 of part A of title XXVII of the 
     Public Health Service Act is amended by adding at the end the 
     following new section:

     ``SEC. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
                   CONGENITAL OR DEVELOPMENTAL DEFORMITY OR 
                   DISORDER.

       ``(a) Requirements for Treatment for Children With 
     Deformities.--
       ``(1) In general.--A group health plan, and a health 
     insurance issuer offering group health insurance coverage, 
     that provides coverage for surgical benefits shall provide 
     coverage for outpatient and inpatient diagnosis and treatment 
     of a minor child's congenital or developmental deformity, 
     disease, or injury. A minor child shall include any 
     individual who is 21 years of age or younger.
       ``(2) Treatment defined.--
       ``(A) In general.--In this section, the term `treatment' 
     includes reconstructive surgical procedures (procedures that 
     are generally performed to improve function, but may also be 
     performed to approximate a normal appearance) that are 
     performed on abnormal structures of the body caused by 
     congenital defects, developmental abnormalities, trauma, 
     infection, tumors, or disease, including--
       ``(i) procedures that do not materially affect the function 
     of the body part being treated; and
       ``(ii) procedures for secondary conditions and follow-up 
     treatment.
       ``(B) Exception.--Such term does not include cosmetic 
     surgery performed to reshape normal structures of the body to 
     improve appearance or self-esteem.
       ``(b) Notice.--A group health plan under this part shall 
     comply with the notice requirement under section 715(b) of 
     the Employee Retirement Income Security Act of 1974 with 
     respect to the requirements of this section as if such 
     section applied to such plan.''.
       (2) Individual health insurance.--Subpart 2 of part B of 
     title XXVII of the Public Health Service Act, as amended by 
     section 161(b), is further amended by adding at the end the 
     following new section:

     ``SEC. 2755. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
                   CONGENITAL OR DEVELOPMENTAL DEFORMITY OR 
                   DISORDER.

       ``The provisions of section 2708 shall apply to health 
     insurance coverage offered by a health insurance issuer in 
     the individual market in the same manner as such provisions 
     apply to health insurance coverage offered by a health 
     insurance issuer in connection with a group health plan in 
     the small or large group market.''.
       (3) Conforming amendments.--
       (A) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is 
     amended by striking ``section 2704'' and inserting ``sections 
     2704 and 2708''.
       (B) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-
     62(b)(2)) is amended by striking ``section 2751'' and 
     inserting ``sections 2751 and 2755''.
       (d) Effective Dates.--
       (1) The amendments made by this section shall apply with 
     respect to group health plans (and health insurance issuers 
     offering group health insurance coverage) for plan years 
     beginning on or after January 1, 2010.
       (2) The amendment made by subsection (c)(2) shall apply 
     with respect to health insurance coverage offered, sold, 
     issued, renewed, in effect, or operated in the individual 
     market on or after such date.
       (e) Coordination.--Section 104(1) of the Health Insurance 
     Portability and Accountability Act of 1996 is amended by 
     striking ``(and the amendments made by this subtitle and 
     section 401)'' and inserting ``, part 7 of subtitle B of 
     title I of the Employee Retirement Income Security Act of 
     1974, parts A and C of title XXVII of the Public Health

[[Page 27221]]

     Service Act, and chapter 100 of the Internal Revenue Code of 
     1986''.

     SEC. 109. ELIMINATION OF LIFETIME LIMITS.

       (a) Amendments to the Employee Retirement Income Security 
     Act of 1974.--
       (1) In general.--Subpart B of part 7 of subtitle B of title 
     I of the Employee Retirement Income Security Act of 1974 (29 
     U.S.C. 1185 et seq.), as amended by section 108, is amended 
     by adding at the end the following:

     ``SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer providing health insurance coverage in 
     connection with a group health plan, may not impose an 
     aggregate dollar lifetime limit with respect to benefits 
     payable under the plan or coverage.
       ``(b) Definition.--In this section, the term `aggregate 
     dollar lifetime limit' means, with respect to benefits under 
     a group health plan or health insurance coverage offered in 
     connection with a group health plan, a dollar limitation on 
     the total amount that may be paid with respect to such 
     benefits under the plan or health insurance coverage with 
     respect to an individual or other coverage unit on a lifetime 
     basis.''.
       (2) Clerical amendment.--The table of contents in section 1 
     of such Act, is amended by inserting after the item relating 
     to section 715 the following new item:

``Sec. 716. Elimination of lifetime aggregate limits.''.
       (b) Amendments to the Internal Revenue Code of 1986.--
       (1) In general.--Subchapter B of chapter 100 of the 
     Internal Revenue Code of 1986, as amended by section 108(b), 
     is amended by adding at the end the following new section:

     ``SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

       ``(a) In General.--A group health plan may not impose an 
     aggregate dollar lifetime limit with respect to benefits 
     payable under the plan.
       ``(b) Definition.--In this section, the term `aggregate 
     dollar lifetime limit' means, with respect to benefits under 
     a group health plan a dollar limitation on the total amount 
     that may be paid with respect to such benefits under the plan 
     with respect to an individual or other coverage unit on a 
     lifetime basis.''.
       (2) Clerical amendment.--The table of sections for 
     subchapter B of chapter 100 of such Code, as amended by 
     section 108(b), is amended by adding at the end the following 
     new item:

``Sec. 9854. Standards relating to benefits for minor child's 
              congenital or developmental deformity or disorder.''.
       (c) Amendment to the Public Health Service Act Relating to 
     the Group Market.--
       (1) In general.--Subpart 2 of part A of title XXVII of the 
     Public Health Service Act (42 U.S.C. 300gg-4 et seq.) as 
     amended by section 108(c)(1), is amended by adding at the end 
     the following:

     ``SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer providing health insurance coverage in 
     connection with a group health plan, may not impose an 
     aggregate dollar lifetime limit with respect to benefits 
     payable under the plan or coverage.
       ``(b) Definition.--In this section, the term `aggregate 
     dollar lifetime limit' means, with respect to benefits under 
     a group health plan or health insurance coverage, a dollar 
     limitation on the total amount that may be paid with respect 
     to such benefits under the plan or health insurance coverage 
     with respect to an individual or other coverage unit on a 
     lifetime basis.''.
       (2) Individual market.--Subpart 2 of part B of title XXVII 
     of the Public Health Service Act (42 U.S.C. 300gg-51 et 
     seq.), as amended by section 108(c)(2), is amended by adding 
     at the end the following:

     ``SEC. 2756. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

       ``The provisions of section 2709 shall apply to health 
     insurance coverage offered by a health insurance issuer in 
     the individual market in the same manner as they apply to 
     health insurance coverage offered by a health insurance 
     issuer in connection with a group health plan in the small or 
     large group market.''.
       (d) Effective Dates.--
       (1) The amendments made by this section shall apply with 
     respect to group health plans (and health insurance issuers 
     offering group health insurance coverage) for plan years 
     beginning on or after January 1, 2010.
       (2) The amendment made by subsection (c)(2) shall apply 
     with respect to health insurance coverage offered, sold, 
     issued, renewed, in effect, or operated in the individual 
     market on or after such date.

     SEC. 110. PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF 
                   RETIREE HEALTH BENEFITS BY GROUP HEALTH PLANS.

       (a) In General.--Part 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974, as amended 
     by sections 108 and 109, is amended by inserting after 
     section 716 the following new section:

     ``SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF 
                   RETIREE HEALTH BENEFITS.

       ``(a) In General.--Every group health plan shall contain a 
     provision which expressly bars the plan, or any fiduciary of 
     the plan, from reducing the benefits provided under the plan 
     to a retired participant, or beneficiary of such participant, 
     if such reduction affects the benefits provided to the 
     participant or beneficiary as of the date the participant 
     retired for purposes of the plan and such reduction occurs 
     after the participant's retirement unless such reduction is 
     also made with respect to active participants. Nothing in 
     this section shall prohibit a plan from enforcing a total 
     aggregate cap on amounts paid for retiree health coverage 
     that is part of the plan at the time of retirement.
       ``(b) No Reduction.--Notwithstanding that a group health 
     plan may contain a provision reserving the general power to 
     amend or terminate the plan or a provision specifically 
     authorizing the plan to make post-retirement reductions in 
     retiree health benefits, it shall be prohibited for any group 
     health plan, whether through amendment or otherwise, to 
     reduce the benefits provided to a retired participant or the 
     participant's beneficiary under the terms of the plan if such 
     reduction of benefits occurs after the date the participant 
     retired for purposes of the plan and reduces benefits that 
     were provided to the participant, or the participant's 
     beneficiary, as of the date the participant retired unless 
     such reduction is also made with respect to active 
     participants.
       ``(c) Reduction Described.-- For purposes of this section, 
     a reduction in benefits--
       ``(1) with respect to premiums occurs under a group health 
     plan when a participant's (or beneficiary's) share of the 
     total premium (or, in the case of a self-insured plan, the 
     costs of coverage) of the plan substantially increases; or
       ``(2) with respect to other cost-sharing and benefits under 
     a group health plan occurs when there is a substantial 
     decrease in the actuarial value of the benefit package under 
     the plan.
     For purposes of this section, the term `substantial' means an 
     increase in the total premium share or a decrease in the 
     actuarial value of the benefit package that is greater than 5 
     percent.''
       (b) Conforming Amendment.--The table of contents in section 
     1 of such Act, as amended by sections 108 and 109, is amended 
     by inserting after the item relating to section 716 the 
     following new item:

``Sec. 717. Protection against postretirement reduction of retiree 
              health benefits.''.
       (c) Waiver.--An employer may, in a form and manner which 
     shall be prescribed by the Secretary of Labor, apply for a 
     waiver from this provision if the employer can reasonably 
     demonstrate that meeting the requirements of this section 
     would impose an undue hardship on the employer.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act.

     SEC. 111. REINSURANCE PROGRAM FOR RETIREES.

       (a) Establishment.--
       (1) In general.--Not later than 90 days after the date of 
     the enactment of this Act, the Secretary of Health and Human 
     Services shall establish a temporary reinsurance program (in 
     this section referred to as the ``reinsurance program'') to 
     provide reimbursement to assist participating employment-
     based plans with the cost of providing health benefits to 
     retirees and to eligible spouses, surviving spouses and 
     dependents of such retirees.
       (2) Definitions.--For purposes of this section:
       (A) The term ``eligible employment-based plan'' means a 
     group health plan or employment-based health plan that--
       (i) is --

       (I) maintained by one or more employers (including without 
     limitation any State or political subdivision thereof, or any 
     agency or instrumentality of any of the foregoing), former 
     employers or employee organizations or associations, or a 
     voluntary employees' beneficiary association, or a committee 
     or board of individuals appointed to administer such plan; or
       (II) a multiemployer plan (as defined in section 3(37) of 
     the Employee Retirement Income Security Act of 1974); and

       (ii) provides health benefits to retirees.
       (B) The term ``health benefits'' means medical, surgical, 
     hospital, prescription drug, and such other benefits as shall 
     be determined by the Secretary, whether self-funded or 
     delivered through the purchase of insurance or otherwise.
       (C) The term ``participating employment-based plan'' means 
     an eligible employment-based plan that is participating in 
     the reinsurance program.
       (D) The term ``retiree'' means, with respect to a 
     participating employment-benefit plan, an individual who--
       (i) is 55 years of age or older;
       (ii) is not eligible for coverage under title XVIII of the 
     Social Security Act; and
       (iii) is not an active employee of an employer maintaining 
     the plan or of any employer that makes or has made 
     substantial contributions to fund such plan.
       (E) The term ``Secretary'' means Secretary of Health and 
     Human Services.

[[Page 27222]]

       (b) Participation.--To be eligible to participate in the 
     reinsurance program, an eligible employment-based plan shall 
     submit to the Secretary an application for participation in 
     the program, at such time, in such manner, and containing 
     such information as the Secretary shall require.
       (c) Payment.--
       (1) Submission of claims.--
       (A) In general.--Under the reinsurance program, a 
     participating employment-based plan shall submit claims for 
     reimbursement to the Secretary which shall contain 
     documentation of the actual costs of the items and services 
     for which each claim is being submitted.
       (B) Basis for claims.--Each claim submitted under 
     subparagraph (A) shall be based on the actual amount expended 
     by the participating employment-based plan involved within 
     the plan year for the appropriate employment based health 
     benefits provided to a retiree or to the spouse, surviving 
     spouse, or dependent of a retiree. In determining the amount 
     of any claim for purposes of this subsection, the 
     participating employment-based plan shall take into account 
     any negotiated price concessions (such as discounts, direct 
     or indirect subsidies, rebates, and direct or indirect 
     remunerations) obtained by such plan with respect to such 
     health benefits. For purposes of calculating the amount of 
     any claim, the costs paid by the retiree or by the spouse, 
     surviving spouse, or dependent of the retiree in the form of 
     deductibles, copayments, and coinsurance shall be included 
     along with the amounts paid by the participating employment-
     based plan.
       (2) Program payments and limit.--If the Secretary 
     determines that a participating employment-based plan has 
     submitted a valid claim under paragraph (1), the Secretary 
     shall reimburse such plan for 80 percent of that portion of 
     the costs attributable to such claim that exceeds $15,000, 
     but is less than $90,000. Such amounts shall be adjusted each 
     year based on the percentage increase in the medical care 
     component of the Consumer Price Index (rounded to the nearest 
     multiple of $1,000) for the year involved.
       (3) Use of payments.--Amounts paid to a participating 
     employment-based plan under this subsection shall only be 
     used to reduce the costs of health care provided by the plan 
     by reducing premium costs for the employer or employee 
     association maintaining the plan, and reducing premium 
     contributions, deductibles, copayments, coinsurance, or other 
     out-of-pocket costs for plan participants and beneficiaries. 
     Where the benefits are provided by an employer to members of 
     a represented bargaining unit, the allocation of payments 
     among these purposes shall be subject to collective 
     bargaining. Amounts paid to the plan under this subsection 
     shall not be used as general revenues by the employer or 
     employee association maintaining the plan or for any other 
     purposes. The Secretary shall develop a mechanism to monitor 
     the appropriate use of such payments by such plans.
       (4) Appeals and program protections.--The Secretary shall 
     establish--
       (A) an appeals process to permit participating employment-
     based plans to appeal a determination of the Secretary with 
     respect to claims submitted under this section; and
       (B) procedures to protect against fraud, waste, and abuse 
     under the program.
       (5) Audits.--The Secretary shall conduct annual audits of 
     claims data submitted by participating employment-based plans 
     under this section to ensure that they are in compliance with 
     the requirements of this section.
       (d) Retiree Reserve Trust Fund.--
       (1) Establishment.--
       (A) In general.--There is established in the Treasury of 
     the United States a trust fund to be known as the ``Retiree 
     Reserve Trust Fund'' (referred to in this section as the 
     ``Trust Fund''), that shall consist of such amounts as may be 
     appropriated or credited to the Trust Fund as provided for in 
     this subsection to enable the Secretary to carry out the 
     reinsurance program. Such amounts shall remain available 
     until expended.
       (B) Funding.--There are hereby appropriated to the Trust 
     Fund, out of any moneys in the Treasury not otherwise 
     appropriated, an amount requested by the Secretary as 
     necessary to carry out this section, except that the total of 
     all such amounts requested shall not exceed $10,000,000,000.
       (C) Appropriations from the trust fund.--
       (i) In general.--Amounts in the Trust Fund are appropriated 
     to provide funding to carry out the reinsurance program and 
     shall be used to carry out such program.
       (ii) Limitation to available funds.--The Secretary has the 
     authority to stop taking applications for participation in 
     the program or take such other steps in reducing expenditures 
     under the reinsurance program in order to ensure that 
     expenditures under the reinsurance program do not exceed the 
     funds available under this subsection.

     SEC. 112. WELLNESS PROGRAM GRANTS.

       (a) Allowance of Grant.--
       (1) In general.--For purposes of this section, the 
     Secretaries of Health and Human Services and Labor shall 
     jointly award wellness grants as determined under this 
     section. Wellness program grants shall be awarded to small 
     employers (as defined by the Secretary) for any plan year in 
     an amount equal to 50 percent of the costs paid or incurred 
     by such employers in connection with a qualified wellness 
     program during the plan year. For purposes of the preceding 
     sentence, in the case of any qualified wellness program 
     offered as part of an employment-based health plan, only 
     costs attributable to the qualified wellness program and not 
     to the health plan, or health insurance coverage offered in 
     connection with such a plan, may be taken into account.
       (2) Limitations.--
       (A) Period.--A wellness grant awarded to an employer under 
     this section shall be for up to 3 years.
       (B) Amount.--The amount of the grant under paragraph (1) 
     for an employer shall not exceed--
       (i) the product of $150 and the number of employees of the 
     employer for any plan year; and
       (ii) $50,000 for the entire period of the grant.
       (b) Qualified Wellness Program.--For purposes of this 
     section:
       (1) Qualified wellness program.--The term ``qualified 
     wellness program'' means a program that --
       (A) includes any 3 wellness components described in 
     subsection (c); and
       (B) is to be certified jointly by the Secretary of Health 
     and Human Services and the Secretary of Labor, in 
     coordination with the Director of the Centers for Disease 
     Control and Prevention, as a qualified wellness program under 
     this section.
       (2) Programs must be consistent with research and best 
     practices.--
       (A) In general.--The Secretary of Health and Human Services 
     and the Secretary of Labor shall not certify a program as a 
     qualified wellness program unless the program--
       (i) is consistent with evidence-based research and best 
     practices, as identified by persons with expertise in 
     employer health promotion and wellness programs;
       (ii) includes multiple, evidence-based strategies which are 
     based on the existing and emerging research and careful 
     scientific reviews, including the Guide to Community 
     Preventative Services, the Guide to Clinical Preventative 
     Services, and the National Registry for Effective Programs, 
     and
       (iii) includes strategies which focus on prevention and 
     support for employee populations at risk of poor health 
     outcomes.
       (B) Periodic updating and review.--The Secretaries of 
     Health and Human Services and Labor, in consultation with 
     other appropriate agencies shall jointly establish procedures 
     for periodic review, evaluation, and update of the programs 
     under this subsection.
       (3) Health literacy and accessibility.--The Secretaries of 
     Health and Human Services and Labor shall jointly, as part of 
     the certification process--
       (A) ensure that employers make the programs culturally 
     competent, physically and programmatically accessible 
     (including for individuals with disabilities), and 
     appropriate to the health literacy needs of the employees 
     covered by the programs;
       (B) require a health literacy component to provide special 
     assistance and materials to employees with low literacy 
     skills, limited English and from underserved populations; and
       (C) require the Secretaries to compile and disseminate to 
     employer health plans information on model health literacy 
     curricula, instructional programs, and effective intervention 
     strategies.
       (c) Wellness Program Components.--For purposes of this 
     section, the wellness program components described in this 
     subsection are the following:
       (1) Health awareness component.--A health awareness 
     component which provides for the following:
       (A) Health education.--The dissemination of health 
     information which addresses the specific needs and health 
     risks of employees.
       (B) Health screenings.--The opportunity for periodic 
     screenings for health problems and referrals for appropriate 
     follow-up measures.
       (2) Employee engagement component.--An employee engagement 
     component which provides for the active engagement of 
     employees in worksite wellness programs through worksite 
     assessments and program planning, onsite delivery, 
     evaluation, and improvement efforts.
       (3) Behavioral change component.--A behavioral change 
     component which encourages healthy living through counseling, 
     seminars, on-line programs, self-help materials, or other 
     programs which provide technical assistance and problem 
     solving skills. Such component may include programs relating 
     to--
       (A) tobacco use;
       (B) obesity;
       (C) stress management;
       (D) physical fitness;
       (E) nutrition;
       (F) substance abuse;
       (G) depression; and
       (H) mental health promotion.
       (4) Supportive environment component.--A supportive 
     environment component which includes the following:
       (A) On-site policies.--Policies and services at the 
     worksite which promote a healthy lifestyle, including 
     policies relating to--
       (i) tobacco use at the worksite;

[[Page 27223]]

       (ii) the nutrition of food available at the worksite 
     through cafeterias and vending options;
       (iii) minimizing stress and promoting positive mental 
     health in the workplace; and
       (iv) the encouragement of physical activity before, during, 
     and after work hours.
       (d) Participation Requirement.--No grant shall be allowed 
     under subsection (a) unless the Secretaries of Health and 
     Human Services and Labor, in consultation with other 
     appropriate agencies, jointly certify, as a part of any 
     certification described in subsection (b), that each wellness 
     program component of the qualified wellness program--
       (1) shall be available to all employees of the employer;
       (2) shall not mandate participation by employees; and
       (3) may provide a financial reward for participation of an 
     individual in such program so long as such reward is not tied 
     to the premium or cost-sharing of the individual under the 
     health benefits plan.
       (e) Privacy Protections.--Data gathered for purposes of the 
     employer wellness program may be used solely for the purposes 
     of administering the program. The Secretaries of Health and 
     Human Services and Labor shall develop standards to ensure 
     such data remain confidential and are not used for purposes 
     beyond those for administering the program.
       (f) Certain Costs Not Included.--For purposes of this 
     section, costs paid or incurred by an employer for food or 
     health insurance shall not be taken into account under 
     subsection (a).
       (g) Outreach.--The Secretaries of Health and Human Services 
     and Labor, in conjunction with other appropriate agencies and 
     members of the business community, shall jointly institute an 
     outreach program to inform businesses about the availability 
     of the wellness program grant as well as to educate 
     businesses on how to develop programs according to recognized 
     and promising practices and on how to measure the success of 
     implemented programs.
       (h) Effective Date.--This section shall take effect on July 
     1, 2010.
       (i) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as are necessary to carry out 
     this section.

     SEC. 113. EXTENSION OF COBRA CONTINUATION COVERAGE.

       (a) Extension of Current Periods of Continuation 
     Coverage.--
       (1) In general.--In the case of any individual who is, 
     under a COBRA continuation coverage provision, covered under 
     COBRA continuation coverage on or after the date of the 
     enactment of this Act, the required period of any such 
     coverage which has not subsequently terminated under the 
     terms of such provision for any reason other than the 
     expiration of a period of a specified number of months shall, 
     notwithstanding such provision and subject to subsection (b), 
     extend to the earlier of the date on which such individual 
     becomes eligible for acceptable coverage or the date on which 
     such individual becomes eligible for health insurance 
     coverage through the Health Insurance Exchange (or a State-
     based Health Insurance Exchange operating in a State or group 
     of States).
       (2) Notice.--As soon as practicable after the date of the 
     enactment of this Act, the Secretary of Labor, in 
     consultation with the Secretary of the Treasury and the 
     Secretary of Health and Human Services, shall, in 
     consultation with administrators of the group health plans 
     (or other entities) that provide or administer the COBRA 
     continuation coverage involved, provide rules setting forth 
     the form and manner in which prompt notice to individuals of 
     the continued availability of COBRA continuation coverage to 
     such individuals under paragraph (1).
       (b) Continued Effect of Other Terminating Events.--
     Notwithstanding subsection (a), any required period of COBRA 
     continuation coverage which is extended under such subsection 
     shall terminate upon the occurrence, prior to the date of 
     termination otherwise provided in such subsection, of any 
     terminating event specified in the applicable continuation 
     coverage provision other than the expiration of a period of a 
     specified number of months.
       (c) Access to State Health Benefits Risk Pools.--This 
     section shall supersede any provision of the law of a State 
     or political subdivision thereof to the extent that such 
     provision has the effect of limiting or precluding access by 
     a qualified beneficiary whose COBRA continuation coverage has 
     been extended under this section to a State health benefits 
     risk pool recognized by the Commissioner for purposes of this 
     section solely by reason of the extension of such coverage 
     beyond the date on which such coverage otherwise would have 
     expired.
       (d) Definitions.--For purposes of this section--
       (1) COBRA continuation coverage.--The term ``COBRA 
     continuation coverage'' means continuation coverage provided 
     pursuant to part 6 of subtitle B of title I of the Employee 
     Retirement Income Security Act of 1974 (other than under 
     section 609), title XXII of the Public Health Service Act, 
     section 4980B of the Internal Revenue Code of 1986 (other 
     than subsection (f)(1) of such section insofar as it relates 
     to pediatric vaccines), or section 905a of title 5, United 
     States Code, or under a State program that provides 
     comparable continuation coverage. Such term does not include 
     coverage under a health flexible spending arrangement under a 
     cafeteria plan within the meaning of section 125 of the 
     Internal Revenue Code of 1986.
       (2) COBRA continuation provision.--The term ``COBRA 
     continuation provision'' means the provisions of law 
     described in paragraph (1).

     SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     provide grants to States (as defined for purposes of title 
     XIX of the Social Security Act) to establish programs to 
     expand access to affordable health care coverage for the 
     uninsured populations in that State in a manner consistent 
     with reforms to take effect under this division in Y1.
       (b) Types of Programs.--The types of programs for which 
     grants are available under subsection (a) include the 
     following:
       (1) State insurance exchanges.--State insurance exchanges 
     that develop new, less expensive, portable benefit packages 
     for small employers and part-time and seasonal workers.
       (2) Community coverage program.--Community coverage with 
     shared responsibility between employers, governmental or 
     nonprofit entity, and the individual.
       (3) Reinsurance plan program.--Reinsurance plans that 
     subsidize a certain share of carrier losses within a certain 
     risk corridor health insurance premium assistance.
       (4) Transparent marketplace program.--Transparent 
     marketplace that provides an organized structure for the sale 
     of insurance products such as a Web exchange or portal.
       (5) Automated enrollment program.--Statewide or automated 
     enrollment systems for public assistance programs.
       (6) Innovative strategies.--Innovative strategies to insure 
     low-income childless adults.
       (7) Purchasing collaboratives.--Not-for-profit business, 
     consumer collaborative that provides direct contract health 
     care service purchasing options for group plan sponsors.
       (c) Eligibility and Administration.--
       (1) Implementation of key statutory or regulatory 
     changes.--In order to be awarded a grant under this section 
     for a program, a State shall demonstrate that--
       (A) it has achieved the key State and local statutory or 
     regulatory changes required to begin implementing the new 
     program within 1 year after the initiation of funding under 
     the grant; and
       (B) it will be able to sustain the program without Federal 
     funding after the end of the period of the grant.
       (2) Ineligibility.--A State that has already developed a 
     comprehensive health insurance access program is not eligible 
     for a grant under this section.
       (3) Application required.--No State shall receive a grant 
     under this section unless the State has approved by the 
     Secretary such an application, in such form and manner as the 
     Secretary specifies.
       (4) Administration based on current program.--The program 
     under this section is intended to build on the State Health 
     Access Program funded under the Omnibus Appropriations Act, 
     2009 (Public Law 111-8).
       (d) Funding Limitations.--
       (1) In general.--A grant under this section shall--
       (A) only be available for expenditures before Y1; and
       (B) only be used to supplement, and not supplant, funds 
     otherwise provided.
       (2) Matching fund requirement.--
       (A) In general.--Subject to subparagraph (B), no grant may 
     be awarded to a State unless the State demonstrates the 
     seriousness of its effort by matching at least 20 percent of 
     the grant amount through non-Federal resources, which may be 
     a combination of State, local, private dollars from insurers, 
     providers, and other private organizations.
       (B) Waiver.--The Secretary may waive the requirement of 
     subparagraph (A) if the State demonstrates to the Secretary 
     financial hardship in complying with such requirement.
       (e) Study.--The Secretary shall review, study, and 
     benchmark the progress and results of the programs funded 
     under this section.
       (f) Report.--Each State receiving a grant under this 
     section shall submit to the Secretary a report on best 
     practices and lessons learned through the grant to inform the 
     health reform coverage expansions under this division 
     beginning in Y1.
       (g) Funding.--There are authorized to be appropriated such 
     sums as may be necessary to carry out this section.

     SEC. 115. ADMINISTRATIVE SIMPLIFICATION.

       (a) Standardizing Electronic Administrative Transactions.--
       (1) In general.--Part C of title XI of the Social Security 
     Act (42 U.S.C. 1320d et seq.) is amended by inserting after 
     section 1173 the following new sections:

     ``SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE 
                   TRANSACTIONS.

       ``(a) Standards for Financial and Administrative 
     Transactions.--

[[Page 27224]]

       ``(1) In general.--The Secretary shall adopt and regularly 
     update standards consistent with the goals described in 
     paragraph (2).
       ``(2) Goals for financial and administrative 
     transactions.--The goals for standards under paragraph (1) 
     are that such standards shall, to the extent practicable--
       ``(A) be unique with no conflicting or redundant standards;
       ``(B) be authoritative, permitting no additions or 
     constraints for electronic transactions, including companion 
     guides;
       ``(C) be comprehensive, efficient and robust, requiring 
     minimal augmentation by paper transactions or clarification 
     by further communications;
       ``(D) enable the real-time (or near real-time) 
     determination of an individual's financial responsibility at 
     the point of service and, to the extent possible, prior to 
     service, including whether the individual is eligible for a 
     specific service with a specific physician at a specific 
     facility, on a specific date or range of dates, include 
     utilization of a machine-readable health plan beneficiary 
     identification card or similar mechanism;
       ``(E) enable, where feasible, near real-time adjudication 
     of claims;
       ``(F) provide for timely acknowledgment, response, and 
     status reporting applicable to any electronic transaction 
     deemed appropriate by the Secretary;
       ``(G) describe all data elements (such as reason and remark 
     codes) in unambiguous terms, not permit optional fields, 
     require that data elements be either required or conditioned 
     upon set values in other fields, and prohibit additional 
     conditions except where required by (or to implement) State 
     or Federal law or to protect against fraud and abuse; and
       ``(H) harmonize all common data elements across 
     administrative and clinical transaction standards.
       ``(3) Time for adoption.--Not later than 2 years after the 
     date of the enactment of this section, the Secretary shall 
     adopt standards under this section by interim, final rule.
       ``(4) Requirements for specific standards.--The standards 
     under this section shall be developed, adopted, and enforced 
     so as to--
       ``(A) clarify, refine, complete, and expand, as needed, the 
     standards required under section 1173;
       ``(B) require paper versions of standardized transactions 
     to comply with the same standards as to data content such 
     that a fully compliant, equivalent electronic transaction can 
     be populated from the data from a paper version;
       ``(C) enable electronic funds transfers, in order to allow 
     automated reconciliation with the related health care payment 
     and remittance advice;
       ``(D) require timely and transparent claim and denial 
     management processes, including uniform claim edits, uniform 
     reason and remark denial codes, tracking, adjudication, and 
     appeal processing;
       ``(E) require the use of a standard electronic transaction 
     with which health care providers may quickly and efficiently 
     enroll with a health plan to conduct the other electronic 
     transactions provided for in this part; and
       ``(F) provide for other requirements relating to 
     administrative simplification as identified by the Secretary, 
     in consultation with stakeholders.
       ``(5) Building on existing standards.--In adopting the 
     standards under this section, the Secretary shall consider 
     existing and planned standards.
       ``(6) Implementation and enforcement.--Not later than 6 
     months after the date of the enactment of this section, the 
     Secretary shall submit to the appropriate committees of 
     Congress a plan for the implementation and enforcement, by 
     not later than 5 years after such date of enactment, of the 
     standards under this section. Such plan shall include--
       ``(A) a process and timeframe with milestones for 
     developing the complete set of standards;
       ``(B) a proposal for accommodating necessary changes 
     between version changes and a process for upgrading standards 
     as often as annually by interim, final rulemaking;
       ``(C) programs to provide incentives for, and ease the 
     burden of, implementation for certain health care providers, 
     with special consideration given to such providers serving 
     rural or underserved areas and ensure coordination with 
     standards, implementation specifications, and certification 
     criteria being adopted under the HITECH Act;
       ``(D) programs to provide incentives for, and ease the 
     burden of, health care providers who volunteer to participate 
     in the process of setting standards for electronic 
     transactions;
       ``(E) an estimate of total funds needed to ensure timely 
     completion of the implementation plan; and
       ``(F) an enforcement process that includes timely 
     investigation of complaints, random audits to ensure 
     compliance, civil monetary and programmatic penalties for 
     noncompliance consistent with existing laws and regulations, 
     and a fair and reasonable appeals process building off of 
     enforcement provisions under this part, and concurrent State 
     enforcement jurisdiction.
     The Secretary may promulgate an annual audit and 
     certification process to ensure that all health plans and 
     clearinghouses are both syntactically and functionally 
     compliant with all the standard transactions mandated 
     pursuant to the administrative simplification provisions of 
     this part and the Health Insurance Portability and 
     Accountability Act of 1996.
       ``(b) Limitations on Use of Data.--Nothing in this section 
     shall be construed to permit the use of information collected 
     under this section in a manner that would violate State or 
     Federal law.
       ``(c) Protection of Data.--The Secretary shall ensure 
     (through the promulgation of regulations or otherwise) that 
     all data collected pursuant to subsection (a) are used and 
     disclosed in a manner that meets the HIPAA privacy and 
     security law (as defined in section 3009(a)(2) of the Public 
     Health Service Act), including any privacy or security 
     standard adopted under section 3004 of such Act.

     ``SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OPERATING 
                   RULES.

       ``(a) In General.--The Secretary shall adopt a single, 
     binding, comprehensive companion guide, that includes 
     operating rules for each X12 Version 5010 transaction 
     described in section 1173(a)(2), to be effective until the 
     new version of these transactions which comply with section 
     1173A are adopted and implemented.
       ``(b) Companion Guide and Operating Rules Development.--In 
     adopting such interim companion guide and rules, the 
     Secretary shall comply with section 1172, except that a 
     nonprofit entity that meets the following criteria shall also 
     be consulted:
       ``(1) The entity focuses its mission on administrative 
     simplification.
       ``(2) The entity uses a multistakeholder process that 
     creates consensus-based companion guides, including operating 
     rules using a voting process that ensures balanced 
     representation by the critical stakeholders (including health 
     plans and health care providers) so that no one group 
     dominates the entity and shall include others such as 
     standards development organizations, and relevant Federal or 
     State agencies.
       ``(3) The entity has in place a public set of guiding 
     principles that ensure the companion guide and operating 
     rules and process are open and transparent.
       ``(4) The entity coordinates its activities with the HIT 
     Policy Committee, and the HIT Standards Committee 
     (established under title XXX of the Public Health Service 
     Act) and complements the efforts of the Office of the 
     National Healthcare Coordinator and its related health 
     information exchange goals.
       ``(5) The entity incorporates the standards issued under 
     Health Insurance Portability and Accountability Act of 1996 
     and this part, and in developing the companion guide and 
     operating rules does not change the definition, data 
     condition or use of a data element or segment in a standard, 
     add any elements or segments to the maximum defined data set, 
     use any codes or data elements that are either marked `not 
     used' in the standard's implementation specifications or are 
     not in the standard's implementation specifications, or 
     change the meaning or intent of the standard's implementation 
     specifications.
       ``(6) The entity uses existing market research and proven 
     best practices.
       ``(7) The entity has a set of measures that allow for the 
     evaluation of their market impact and public reporting of 
     aggregate stakeholder impact.
       ``(8) The entity supports nondiscrimination and conflict of 
     interest policies that demonstrate a commitment to open, 
     fair, and nondiscriminatory practices.
       ``(9) The entity allows for public reviews and comment on 
     updates of the companion guide, including the operating 
     rules.
       ``(c) Implementation.--The Secretary shall adopt a single, 
     binding companion guide, including operating rules under this 
     section, for each transaction, to become effective with the 
     X12 Version 5010 transaction implementation, or as soon 
     thereafter as feasible. The companion guide, including 
     operating rules for the transactions for eligibility for 
     health plan and health claims status under this section shall 
     be adopted not later than October 1, 2011, in a manner such 
     that such set of rules is effective beginning not later than 
     January 1, 2013. The companion guide, including operating 
     rules for the remainder of the transactions described in 
     section 1173(a)(2) shall be adopted not later than October 1, 
     2012, in a manner such that such set of rules is effective 
     beginning not later than January 1, 2014.''.
       (2) Definitions.--Section 1171 of such Act (42 U.S.C. 
     1320d) is amended--
       (A) in paragraph (1), by inserting ``, and associated 
     operational guidelines and instructions, as determined 
     appropriate by the Secretary'' after ``medical procedure 
     codes''; and
       (B) by adding at the end the following new paragraph:
       ``(10) Operating rules.--The term `operating rules' means 
     business rules for using and processing transactions, such as 
     service level requirements, which do not impact the 
     implementation specifications or other data content 
     requirements.''.
       (3) Conforming amendment.--Section 1179(a) of such Act (42 
     U.S.C. 1320d-8(a)) is amended, in the matter before paragraph 
     (1)--
       (A) by inserting ``on behalf of an individual'' after 
     ``1978)''; and

[[Page 27225]]

       (B) by inserting ``on behalf of an individual'' after ``for 
     a financial institution'' and
       (b) Standards for Claims Attachments and Coordination of 
     Benefits.--
       (1) Standard for health claims attachments.--Not later than 
     1 year after the date of the enactment of this Act, the 
     Secretary of Health and Human Services shall promulgate an 
     interim, final rule to establish a standard for health claims 
     attachment transaction described in section 1173(a)(2)(B) of 
     the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and 
     coordination of benefits.
       (2) Revision in processing payment transactions by 
     financial institutions.--
       (A) In general.--Section 1179 of the Social Security Act 
     (42 U.S.C. 1320d-8) is amended, in the matter before 
     paragraph (1)--
       (i) by striking ``or is engaged'' and inserting ``and is 
     engaged''; and
       (ii) by inserting ``(other than as a business associate for 
     a covered entity)'' after ``for a financial institution''.
       (B) Compliance date.--The amendments made by subparagraph 
     (A) shall apply to transactions occurring on or after such 
     date (not later than January 1, 2014) as the Secretary of 
     Health and Human Services shall specify.
       (c) Standards for First Report of Injury.--Not later than 
     January 1, 2014, the Secretary of Health and Human Services 
     shall promulgate an interim final rule to establish a 
     standard for the first report of injury transaction described 
     in section 1173(a)(2)(G) of the Social Security Act (42 
     U.S.C. 1320d-2(a)(2)(G)).
       (d) Unique Health Plan Identifier.--Not later October 1, 
     2012, the Secretary of Health and Human Services shall 
     promulgate an interim final rule to establish a unique health 
     plan identifier described in section 1173(b) of the Social 
     Security Act (42 U.S.C. 1320d-2(b)) based on the input of the 
     National Committee of Vital and Health Statistics and 
     consultation with health plans, health care providers, and 
     other interested parties.
       (e) Expansion of Electronic Transactions in Medicare.--
     Section 1862(a) of the Social Security Act (42 U.S.C. 
     1395y(a)) is amended--
       (1) in paragraph (23), by striking ``or'' at the end;
       (2) in paragraph (24), by striking the period and inserting 
     ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) subject to subsection (h), not later than January 1, 
     2015, for which the payment is other than by electronic funds 
     transfer (EFT) so long as the Secretary has adopted and 
     implemented a standard for electronic funds transfer under 
     section 1173A.''.
       (f) Expansion of Penalties.--Section 1176 of such Act (42 
     U.S.C. 1320d-5) is amended by adding at the end the following 
     new subsection:
       ``(c) Expansion of Penalty Authority.--The Secretary may, 
     in addition to the penalties provided under subsections (a) 
     and (b), provide for the imposition of penalties for 
     violations of this part that are comparable--
       ``(1) in the case of health plans, to the sanctions the 
     Secretary is authorized to impose under part C or D of title 
     XVIII in the case of a plan that violates a provision of such 
     part; or
       ``(2) in the case of a health care provider, to the 
     sanctions the Secretary is authorized to impose under part A, 
     B, or D of title XVIII in the case of a health care provider 
     that violations a provision of such part with respect to that 
     provider.''.

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

                     Subtitle A--General Standards

     SEC. 201. REQUIREMENTS REFORMING HEALTH INSURANCE 
                   MARKETPLACE.

       (a) Purpose.--The purpose of this title is to establish 
     standards to ensure that new health insurance coverage and 
     employment-based health plans that are offered meet standards 
     guaranteeing access to affordable coverage, essential 
     benefits, and other consumer protections.
       (b) Requirements for Qualified Health Benefits Plans.--On 
     or after the first day of Y1, a health benefits plan shall 
     not be a qualified health benefits plan under this division 
     unless the plan meets the applicable requirements of the 
     following subtitles for the type of plan and plan year 
     involved:
       (1) Subtitle B (relating to affordable coverage).
       (2) Subtitle C (relating to essential benefits).
       (3) Subtitle D (relating to consumer protection).
       (c) Terminology.--In this division:
       (1) Enrollment in employment-based health plans.--An 
     individual shall be treated as being ``enrolled'' in an 
     employment-based health plan if the individual is a 
     participant or beneficiary (as such terms are defined in 
     section 3(7) and 3(8), respectively, of the Employee 
     Retirement Income Security Act of 1974) in such plan.
       (2) Individual and group health insurance coverage.--The 
     terms ``individual health insurance coverage'' and ``group 
     health insurance coverage'' mean health insurance coverage 
     offered in the individual market or large or small group 
     market, respectively, as defined in section 2791 of the 
     Public Health Service Act.
       (d) Treatment of Qualified Direct Primary Care Medical Home 
     Plans.--The Commissioner may permit a qualified health 
     benefits plan to provide coverage through a qualified direct 
     primary care medical home plan so long as the qualified 
     health benefits plan meets all requirements that are 
     otherwise applicable and the services covered by the medical 
     home plan are coordinated with the QHBP offering entity.

     SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

       (a) Grandfathered Health Insurance Coverage Defined.--
     Subject to the succeeding provisions of this section, for 
     purposes of establishing acceptable coverage under this 
     division, the term ``grandfathered health insurance 
     coverage'' means individual health insurance coverage that is 
     offered and in force and effect before the first day of Y1 if 
     the following conditions are met:
       (1) Limitation on new enrollment.--
       (A) In general.--Except as provided in this paragraph, the 
     individual health insurance issuer offering such coverage 
     does not enroll any individual in such coverage if the first 
     effective date of coverage is on or after the first day of 
     Y1.
       (B) Dependent coverage permitted.--Subparagraph (A) shall 
     not affect the subsequent enrollment of a dependent of an 
     individual who is covered as of such first day.
       (2) Limitation on changes in terms or conditions.--Subject 
     to paragraph (3) and except as required by law, the issuer 
     does not change any of its terms or conditions, including 
     benefits and cost-sharing, from those in effect as of the day 
     before the first day of Y1.
       (3) Restrictions on premium increases.--The issuer cannot 
     vary the percentage increase in the premium for a risk group 
     of enrollees in specific grandfathered health insurance 
     coverage without changing the premium for all enrollees in 
     the same risk group at the same rate, as specified by the 
     Commissioner.
       (b) Grace Period for Current Employment-Based Health 
     Plans.--
       (1) Grace period.--
       (A) In general.--The Commissioner shall establish a grace 
     period whereby, for plan years beginning after the end of the 
     5-year period beginning with Y1, an employment-based health 
     plan in operation as of the day before the first day of Y1 
     must meet the same requirements as apply to a qualified 
     health benefits plan under section 201, including the 
     essential benefit package requirement under section 221.
       (B) Exception for limited benefits plans.--Subparagraph (A) 
     shall not apply to an employment-based health plan in which 
     the coverage consists only of one or more of the following:
       (i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) 
     of division B of the American Recovery and Reinvestment Act 
     of 2009 (Public Law 111-5).
       (ii) Excepted benefits (as defined in section 733(c) of the 
     Employee Retirement Income Security Act of 1974), including 
     coverage under a specified disease or illness policy 
     described in paragraph (3)(A) of such section.
       (iii) Such other limited benefits as the Commissioner may 
     specify.

     In no case shall an employment-based health plan in which the 
     coverage consists only of one or more of the coverage or 
     benefits described in clauses (i) through (iii) be treated as 
     acceptable coverage under this division.
       (2) Transitional treatment as acceptable coverage.--During 
     the grace period specified in paragraph (1)(A), an 
     employment-based health plan (which may be a high deducible 
     health plan, as defined in section 223(c)(2) of the Internal 
     Revenue Code of 1986) that is described in such paragraph 
     shall be treated as acceptable coverage under this division.
       (c) Limitation on Individual Health Insurance Coverage.--
       (1) In general.--Individual health insurance coverage that 
     is not grandfathered health insurance coverage under 
     subsection (a) may only be offered on or after the first day 
     of Y1 as an Exchange-participating health benefits plan.
       (2) Separate, excepted coverage permitted.--Nothing in--
       (A) paragraph (1) shall prevent the offering of excepted 
     benefits described in section 2791(c) of the Public Health 
     Service Act so long as such benefits are offered outside the 
     Health Insurance Exchange and are priced separately from 
     health insurance coverage; and
       (B) this division shall be construed--
       (i) to prevent the offering of a stand-alone plan that 
     offers coverage of excepted benefits described in section 
     2791(c)(2)(A) of the Public Health Service Act (relating to 
     limited scope dental or vision benefits) for individuals and 
     families from a State-licensed dental and vision carrier; or
       (ii) as applying requirements for a qualified health 
     benefits plan to such a stand-alone plan that is offered and 
     priced separately from a qualified health benefits plan.

    Subtitle B--Standards Guaranteeing Access to Affordable Coverage

     SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.

       A qualified health benefits plan may not impose any 
     preexisting condition exclusion

[[Page 27226]]

     (as defined in section 2701(b)(1)(A) of the Public Health 
     Service Act) or otherwise impose any limit or condition on 
     the coverage under the plan with respect to an individual or 
     dependent based on any of the following: health status, 
     medical condition, claims experience, receipt of health care, 
     medical history, genetic information, evidence of 
     insurability, disability, or source of injury (including 
     conditions arising out of acts of domestic violence) or any 
     similar factors.

     SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS AND 
                   PROHIBITING RESCISSIONS.

       The requirements of sections 2711 (other than subsections 
     (e) and (f)) and 2712 (other than paragraphs (3), and (6) of 
     subsection (b) and subsection (e)) of the Public Health 
     Service Act, relating to guaranteed availability and 
     renewability of health insurance coverage, shall apply to 
     individuals and employers in all individual and group health 
     insurance coverage, whether offered to individuals or 
     employers through the Health Insurance Exchange, through any 
     employment-based health plan, or otherwise, in the same 
     manner as such sections apply to employers and health 
     insurance coverage offered in the small group market, except 
     that such section 2712(b)(1) shall apply only if, before 
     nonrenewal or discontinuation of coverage, the issuer has 
     provided the enrollee with notice of nonpayment of premiums 
     and there is a grace period during which the enrollee has an 
     opportunity to correct such nonpayment. Rescissions of such 
     coverage shall be prohibited except in cases of fraud as 
     defined in section 2712(b)(2) of such Act.

     SEC. 213. INSURANCE RATING RULES.

       (a) In General.--The premium rate charged for a qualified 
     health benefits plan that is health insurance coverage may 
     not vary except as follows:
       (1) Limited age variation permitted.--By age (within such 
     age categories as the Commissioner shall specify) so long as 
     the ratio of the highest such premium to the lowest such 
     premium does not exceed the ratio of 2 to 1.
       (2) By area.--By premium rating area (as permitted by State 
     insurance regulators or, in the case of Exchange-
     participating health benefits plans, as specified by the 
     Commissioner in consultation with such regulators).
       (3) By family enrollment.--By family enrollment (such as 
     variations within categories and compositions of families) so 
     long as the ratio of the premium for family enrollment (or 
     enrollments) to the premium for individual enrollment is 
     uniform, as specified under State law and consistent with 
     rules of the Commissioner.
       (b) Actuarial Value of Optional Service Coverage.--
       (1) In general.--The Commissioner shall estimate the basic 
     per enrollee, per month cost, determined on an average 
     actuarial basis, for including coverage under a basic plan of 
     the services described in section 222(e)(4)(A).
       (2) Considerations.--In making such estimate the 
     Commissioner--
       (A) may take into account the impact on overall costs of 
     the inclusion of such coverage, but may not take into account 
     any cost reduction estimated to result from such services, 
     including prenatal care, delivery, or postnatal care;
       (B) shall estimate such costs as if such coverage were 
     included for the entire population covered; and
       (C) may not estimate such a cost at less than $1 per 
     enrollee, per month.
       (c) Study and Reports.--
       (1) Study.--The Commissioner, in coordination with the 
     Secretary of Health and Human Services and the Secretary of 
     Labor, shall conduct a study of the large-group-insured and 
     self-insured employer health care markets. Such study shall 
     examine the following:
       (A) The types of employers by key characteristics, 
     including size, that purchase insured products versus those 
     that self-insure.
       (B) The similarities and differences between typical 
     insured and self-insured health plans.
       (C) The financial solvency and capital reserve levels of 
     employers that self-insure by employer size.
       (D) The risk of self-insured employers not being able to 
     pay obligations or otherwise becoming financially insolvent.
       (E) The extent to which rating rules are likely to cause 
     adverse selection in the large group market or to encourage 
     small and midsize employers to self-insure.
       (2) Reports.--Not later than 18 months after the date of 
     the enactment of this Act, the Commissioner shall submit to 
     Congress and the applicable agencies a report on the study 
     conducted under paragraph (1). Such report shall include any 
     recommendations the Commissioner deems appropriate to ensure 
     that the law does not provide incentives for small and 
     midsize employers to self-insure or create adverse selection 
     in the risk pools of large group insurers and self-insured 
     employers. Not later than 18 months after the first day of 
     Y1, the Commissioner shall submit to Congress and the 
     applicable agencies an updated report on such study, 
     including updates on such recommendations.

     SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL 
                   HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

       (a) Nondiscrimination in Benefits.--A qualified health 
     benefits plan shall comply with standards established by the 
     Commissioner to prohibit discrimination in health benefits or 
     benefit structures for qualifying health benefits plans, 
     building from section 702 of the Employee Retirement Income 
     Security Act of 1974, section 2702 of the Public Health 
     Service Act, and section 9802 of the Internal Revenue Code of 
     1986.
       (b) Parity in Mental Health and Substance Abuse Disorder 
     Benefits.--To the extent such provisions are not superceded 
     by or inconsistent with subtitle C, the provisions of section 
     2705 (other than subsections (a)(1), (a)(2), and (c)) of the 
     Public Health Service Act shall apply to a qualified health 
     benefits plan, regardless of whether it is offered in the 
     individual or group market, in the same manner as such 
     provisions apply to health insurance coverage offered in the 
     large group market.

     SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.

       (a) In General.--A qualified health benefits plan that uses 
     a provider network for items and services shall meet such 
     standards respecting provider networks as the Commissioner 
     may establish to assure the adequacy of such networks in 
     ensuring enrollee access to such items and services and 
     transparency in the cost-sharing differentials among 
     providers participating in the network and policies for 
     accessing out-of-network providers.
       (b) Internet Access to Information.--A qualified health 
     benefits plan that uses a provider network shall provide a 
     current listing of all providers in its network on its 
     Website and such data shall be available on the Health 
     Insurance Exchange Website as a part of the basic information 
     on that plan. The Commissioner shall also establish an on-
     line system whereby an individual may select by name any 
     medical provider (as defined by the Commissioner) and be 
     informed of the plan or plans with which that provider is 
     contracting.
       (c) Provider Network Defined.--In this division, the term 
     ``provider network'' means the providers with respect to 
     which covered benefits, treatments, and services are 
     available under a health benefits plan.

     SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT 
                   COVERAGE FOR UNINSURED YOUNG ADULTS.

       (a) In General.--A qualified health benefits plan shall 
     make available, at the option of the principal enrollee under 
     the plan, coverage for one or more qualified children (as 
     defined in subsection (b)) of the enrollee.
       (b) Qualified Child Defined.--In this section, the term 
     ``qualified child'' means, with respect to a principal 
     enrollee in a qualified health benefits plan, an individual 
     who (but for age) would be treated as a dependent child of 
     the enrollee under such plan and who--
       (1) is under 27 years of age; and
       (2) is not enrolled in a health benefits plan other than 
     under this section.
       (c) Premiums.--Nothing in this section shall be construed 
     as preventing a qualified health benefits plan from 
     increasing the premiums otherwise required for coverage 
     provided under this section consistent with standards 
     established by the Commissioner based upon family size under 
     section 213(a)(3).

     SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED 
                   HEALTH BENEFITS PLANS DURING PLAN YEAR.

       In the case of health insurance coverage offered under a 
     qualified health benefits plan, if the coverage decreases or 
     the cost-sharing increases, the issuer of the coverage shall 
     notify enrollees of the change at least 90 days before the 
     change takes effect (or such shorter period of time in cases 
     where the change is necessary to ensure the health and safety 
     of enrollees).

    Subtitle C--Standards Guaranteeing Access to Essential Benefits

     SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

       (a) In General.--A qualified health benefits plan shall 
     provide coverage that at least meets the benefit standards 
     adopted under section 224 for the essential benefits package 
     described in section 222 for the plan year involved.
       (b) Choice of Coverage.--
       (1) Non-exchange-participating health benefits plans.--In 
     the case of a qualified health benefits plan that is not an 
     Exchange-participating health benefits plan, such plan may 
     offer such coverage in addition to the essential benefits 
     package as the QHBP offering entity may specify.
       (2) Exchange-participating health benefits plans.--In the 
     case of an Exchange-participating health benefits plan, such 
     plan is required under section 203 to provide specified 
     levels of benefits and, in the case of a plan offering a 
     premium-plus level of benefits, provide additional benefits.
       (3) Continuation of offering of separate excepted benefits 
     coverage.--Nothing in this division shall be construed as 
     affecting the offering outside of the Health Insurance 
     Exchange and under State law of health benefits in the form 
     of excepted benefits (described in section 202(b)(1)(B)(ii)) 
     if such benefits are offered under a separate policy, 
     contract, or certificate of insurance.

[[Page 27227]]

       (c) Clinical Appropriateness.--Nothing in this Act shall be 
     construed to prohibit a group health plan or health insurance 
     issuer from using medical management practices so long as 
     such management practices are based on valid medical evidence 
     and are relevant to the patient whose medical treatment is 
     under review.
       (d) Provision of Benefits.--Nothing in this division shall 
     be construed as prohibiting a qualified health benefits plan 
     from subcontracting with stand-alone health insurance issuers 
     or insurers for the provision of dental, vision, mental 
     health, and other benefits and services.

     SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED.

       (a) In General.--In this division, the term ``essential 
     benefits package'' means health benefits coverage, consistent 
     with standards adopted under section 224, to ensure the 
     provision of quality health care and financial security, 
     that--
       (1) provides payment for the items and services described 
     in subsection (b) in accordance with generally accepted 
     standards of medical or other appropriate clinical or 
     professional practice;
       (2) limits cost-sharing for such covered health care items 
     and services in accordance with such benefit standards, 
     consistent with subsection (c);
       (3) does not impose any annual or lifetime limit on the 
     coverage of covered health care items and services;
       (4) complies with section 215(a) (relating to network 
     adequacy); and
       (5) is equivalent in its scope of benefits, as certified by 
     Office of the Actuary of the Centers for Medicare & Medicaid 
     Services, to the average prevailing employer-sponsored 
     coverage in Y1.

      In order to carry out paragraph (5), the Secretary of Labor 
     shall conduct a survey of employer-sponsored coverage to 
     determine the benefits typically covered by employers, 
     including multiemployer plans, and provide a report on such 
     survey to the Health Benefits Advisory Committee and to the 
     Secretary of Health and Human Services.
       (b) Minimum Services To Be Covered.--Subject to subsection 
     (d), the items and services described in this subsection are 
     the following:
       (1) Hospitalization.
       (2) Outpatient hospital and outpatient clinic services, 
     including emergency department services.
       (3) Professional services of physicians and other health 
     professionals.
       (4) Such services, equipment, and supplies incident to the 
     services of a physician's or a health professional's delivery 
     of care in institutional settings, physician offices, 
     patients' homes or place of residence, or other settings, as 
     appropriate.
       (5) Prescription drugs.
       (6) Rehabilitative and habilitative services.
       (7) Mental health and substance use disorder services, 
     including behavioral health treatments.
       (8) Preventive services, including those services 
     recommended with a grade of A or B by the Task Force on 
     Clinical Preventive Services and those vaccines recommended 
     for use by the Director of the Centers for Disease Control 
     and Prevention.
       (9) Maternity care.
       (10) Well-baby and well-child care and oral health, vision, 
     and hearing services, equipment, and supplies for children 
     under 21 years of age.
       (11) Durable medical equipment, prosthetics, orthotics and 
     related supplies.
       (c) Requirements Relating to Cost-Sharing and Minimum 
     Actuarial Value.--
       (1) No cost-sharing for preventive services.--There shall 
     be no cost-sharing under the essential benefits package for--
       (A) preventive items and services recommended with a grade 
     of A or B by the Task Force on Clinical Preventive Services 
     and those vaccines recommended for use by the Director of the 
     Centers for Disease Control and Prevention; or
       (B) well-baby and well-child care.
       (2) Annual limitation.--
       (A) Annual limitation.--The cost-sharing incurred under the 
     essential benefits package with respect to an individual (or 
     family) for a year does not exceed the applicable level 
     specified in subparagraph (B).
       (B) Applicable level.--The applicable level specified in 
     this subparagraph for Y1 is not to exceed $5,000 for an 
     individual and not to exceed $10,000 for a family. Such 
     levels shall be increased (rounded to the nearest $100) for 
     each subsequent year by the annual percentage increase in the 
     enrollment-weighted average of premium increases for basic 
     plans applicable to such year, except that Secretary shall 
     adjust such increase to ensure that the applicable level 
     specified in this subparagraph meets the minimum actuarial 
     value required under paragraph (3).
       (C) Use of copayments.--In establishing cost-sharing levels 
     for basic, enhanced, and premium plans under this subsection, 
     the Secretary shall, to the maximum extent possible, use only 
     copayments and not coinsurance.
       (3) Minimum actuarial value.--
       (A) In general.--The cost-sharing under the essential 
     benefits package shall be designed to provide a level of 
     coverage that is designed to provide benefits that are 
     actuarially equivalent to approximately 70 percent of the 
     full actuarial value of the benefits provided under the 
     reference benefits package described in subparagraph (B).
       (B) Reference benefits package described.--The reference 
     benefits package described in this subparagraph is the 
     essential benefits package if there were no cost-sharing 
     imposed.
       (d) Assessment and Counseling for Domestic Violence.--The 
     Secretary shall support the need for an assessment and brief 
     counseling for domestic violence as part of a behavioral 
     health assessment or primary care visit and determine the 
     appropriate coverage for such assessment and counseling.
       (e) Abortion Coverage Prohibited as Part of Minimum 
     Benefits Package.--
       (1) Prohibition of required coverage.--The Health Benefits 
     Advisory Committee may not recommend under section 223(b), 
     and the Secretary may not adopt in standards under section 
     224(b), the services described in paragraph (4)(A) or (4)(B) 
     as part of the essential benefits package and the 
     Commissioner may not require such services for qualified 
     health benefits plans to participate in the Health Insurance 
     Exchange.
       (2) Voluntary choice of coverage by plan.--In the case of a 
     qualified health benefits plan, the plan is not required (or 
     prohibited) under this Act from providing coverage of 
     services described in paragraph (4)(A) or (4)(B) and the QHBP 
     offering entity shall determine whether such coverage is 
     provided.
       (3) Coverage under public health insurance option.--The 
     public health insurance option shall provide coverage for 
     services described in paragraph (4)(B). Nothing in this Act 
     shall be construed as preventing the public health insurance 
     option from providing for or prohibiting coverage of services 
     described in paragraph (4)(A).
       (4) Abortion services.--
       (A) Abortions for which public funding is prohibited.--The 
     services described in this subparagraph are abortions for 
     which the expenditure of Federal funds appropriated for the 
     Department of Health and Human Services is not permitted, 
     based on the law as in effect as of the date that is 6 months 
     before the beginning of the plan year involved.
       (B) Abortions for which public funding is allowed.--The 
     services described in this subparagraph are abortions for 
     which the expenditure of Federal funds appropriated for the 
     Department of Health and Human Services is permitted, based 
     on the law as in effect as of the date that is 6 months 
     before the beginning of the plan year involved.
       (f) Report Regarding Inclusion of Oral Health Care in 
     Essential Benefits Package.--Not later than 1 year after the 
     date of the enactment of this Act, the Secretary of Health 
     and Human Services shall submit to Congress a report 
     containing the results of a study determining the need and 
     cost of providing accessible and affordable oral health care 
     to adults as part of the essential benefits package.

     SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE.

       (a) Establishment.--
       (1) In general.--There is established a private-public 
     advisory committee which shall be a panel of medical and 
     other experts to be known as the Health Benefits Advisory 
     Committee to recommend covered benefits and essential, 
     enhanced, and premium plans.
       (2) Chair.--The Surgeon General shall be a member and the 
     chair of the Health Benefits Advisory Committee.
       (3) Membership.--The Health Benefits Advisory Committee 
     shall be composed of the following members, in addition to 
     the Surgeon General:
       (A) Nine members who are not Federal employees or officers 
     and who are appointed by the President.
       (B) Nine members who are not Federal employees or officers 
     and who are appointed by the Comptroller General of the 
     United States in a manner similar to the manner in which the 
     Comptroller General appoints members to the Medicare Payment 
     Advisory Commission under section 1805(c) of the Social 
     Security Act.
       (C) Such even number of members (not to exceed 8) who are 
     Federal employees and officers, as the President may appoint.
     Such initial appointments shall be made not later than 60 
     days after the date of the enactment of this Act.
       (4) Terms.--Each member of the Health Benefits Advisory 
     Committee shall serve a 3-year term on the Committee, except 
     that the terms of the initial members shall be adjusted in 
     order to provide for a staggered term of appointment for all 
     such members.
       (5) Participation.--The membership of the Health Benefits 
     Advisory Committee shall at least reflect providers, patient 
     representatives, employers (including small employers), 
     labor, health insurance issuers, experts in health care 
     financing and delivery, experts in oral health care, experts 
     in racial and ethnic disparities, experts on health care 
     needs and disparities of individuals with disabilities, 
     representatives of relevant governmental agencies, and at 
     least one practicing physician or other health professional 
     and an expert in child and adolescent health and shall 
     represent a balance among various sectors of the health care 
     system so that no single sector unduly influences the 
     recommendations of such Committee.
       (b) Duties.--

[[Page 27228]]

       (1) Recommendations on benefit standards.--The Health 
     Benefits Advisory Committee shall recommend to the Secretary 
     of Health and Human Services (in this subtitle referred to as 
     the ``Secretary'') benefit standards (as defined in paragraph 
     (5)), and periodic updates to such standards. In developing 
     such recommendations, the Committee shall take into account 
     innovation in health care and consider how such standards 
     could reduce health disparities.
       (2) Deadline.--The Health Benefits Advisory Committee shall 
     recommend initial benefit standards to the Secretary not 
     later than 1 year after the date of the enactment of this 
     Act.
       (3) State input.--The Health Benefits Advisory Committee 
     shall examine the health coverage laws and benefits of each 
     State in developing recommendations under this subsection and 
     may incorporate such coverage and benefits as the Committee 
     determines to be appropriate and consistent with this Act. 
     The Health Benefits Advisory Committee shall also seek input 
     from the States and consider recommendations on how to ensure 
     quality of health coverage in all States.
       (4) Public input.--The Health Benefits Advisory Committee 
     shall allow for public input as a part of developing 
     recommendations under this subsection.
       (5) Benefit standards defined.--In this subtitle, the term 
     ``benefit standards'' means standards respecting--
       (A) the essential benefits package described in section 
     222, including categories of covered treatments, items and 
     services within benefit classes, and cost-sharing consistent 
     with subsection (e) of such section; and
       (B) the cost-sharing levels for enhanced plans and premium 
     plans (as provided under section 303(c)) consistent with 
     paragraph (5).
       (6) Levels of cost-sharing for enhanced and premium 
     plans.--
       (A) Enhanced plan.--The level of cost-sharing for enhanced 
     plans shall be designed so that such plans have benefits that 
     are actuarially equivalent to approximately 85 percent of the 
     actuarial value of the benefits provided under the reference 
     benefits package described in section 222(c)(3)(B).
       (B) Premium plan.--The level of cost-sharing for premium 
     plans shall be designed so that such plans have benefits that 
     are actuarially equivalent to approximately 95 percent of the 
     actuarial value of the benefits provided under the reference 
     benefits package described in section 222(c)(3)(B).
       (c) Operations.--
       (1) Per diem pay.--Each member of the Health Benefits 
     Advisory Committee shall receive travel expenses, including 
     per diem in accordance with applicable provisions under 
     subchapter I of chapter 57 of title 5, United States Code, 
     and shall otherwise serve without additional pay.
       (2) Members not treated as federal employees.--Members of 
     the Health Benefits Advisory Committee shall not be 
     considered employees of the Federal Government solely by 
     reason of any service on the Committee, except such members 
     shall be considered to be within the meaning of section 
     202(a) of title 18, United States Code, for the purposes of 
     disclosure and management of conflicts of interest.
       (3) Application of faca.--The Federal Advisory Committee 
     Act (5 U.S.C. App.), other than section 14, shall apply to 
     the Health Benefits Advisory Committee.
       (d) Publication.--The Secretary shall provide for 
     publication in the Federal Register and the posting on the 
     Internet Website of the Department of Health and Human 
     Services of all recommendations made by the Health Benefits 
     Advisory Committee under this section.

     SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION 
                   OF BENEFIT STANDARDS.

       (a) Process for Adoption of Recommendations.--
       (1) Review of recommended standards.--Not later than 45 
     days after the date of receipt of benefit standards 
     recommended under section 223 (including such standards as 
     modified under paragraph (2)(B)), the Secretary shall review 
     such standards and shall determine whether to propose 
     adoption of such standards as a package.
       (2) Determination to adopt standards.--If the Secretary 
     determines--
       (A) to propose adoption of benefit standards so recommended 
     as a package, the Secretary shall, by regulation under 
     section 553 of title 5, United States Code, propose adoption 
     of such standards; or
       (B) not to propose adoption of such standards as a package, 
     the Secretary shall notify the Health Benefits Advisory 
     Committee in writing of such determination and the reasons 
     for not proposing the adoption of such recommendation and 
     provide the Committee with a further opportunity to modify 
     its previous recommendations and submit new recommendations 
     to the Secretary on a timely basis.
       (3) Contingency.--If, because of the application of 
     paragraph (2)(B), the Secretary would otherwise be unable to 
     propose initial adoption of such recommended standards by the 
     deadline specified in subsection (b)(1), the Secretary shall, 
     by regulation under section 553 of title 5, United States 
     Code, propose adoption of initial benefit standards by such 
     deadline.
       (4) Publication.--The Secretary shall provide for 
     publication in the Federal Register of all determinations 
     made by the Secretary under this subsection.
       (b) Adoption of Standards.--
       (1) Initial standards.--Not later than 18 months after the 
     date of the enactment of this Act, the Secretary shall, 
     through the rulemaking process consistent with subsection 
     (a), adopt an initial set of benefit standards.
       (2) Periodic updating standards.--Under subsection (a), the 
     Secretary shall provide for the periodic updating of the 
     benefit standards previously adopted under this section.
       (3) Requirement.--The Secretary may not adopt any benefit 
     standards for an essential benefits package or for level of 
     cost-sharing that are inconsistent with the requirements for 
     such a package or level under sections 222 (including 
     subsection (e)) and 223(b)(5).

              Subtitle D--Additional Consumer Protections

     SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY HEALTH 
                   INSURERS.

       The Commissioner shall establish uniform marketing 
     standards that all QHBP offering entities shall meet with 
     respect to qualified health benefits plans that are health 
     insurance coverage.

     SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

       (a) In General.--A QHBP offering entity shall provide for 
     timely grievance and appeals mechanisms with respect to 
     qualified health benefits plans that the Commissioner shall 
     establish consistent with this section. The Commissioner 
     shall establish time limits for each of such mechanisms and 
     implement them in a manner that is protective to the needs of 
     patients.
       (b) Internal Claims and Appeals Process.--Under a qualified 
     health benefits plan the QHBP offering entity shall provide 
     an internal claims and appeals process that initially 
     incorporates the claims and appeals procedures (including 
     urgent claims) set forth at section 2560.503-1 of title 29, 
     Code of Federal Regulations, as published on November 21, 
     2000 (65 Fed. Reg. 70246) and shall update such process in 
     accordance with any standards that the Commissioner may 
     establish.
       (c) External Review Process.--
       (1) In general.--The Commissioner shall establish an 
     external review process (including procedures for expedited 
     reviews of urgent claims) that provides for an impartial, 
     independent, and de novo review of denied claims under this 
     division.
       (2) Requiring fair grievance and appeals mechanisms.--A 
     determination made, with respect to a qualified health 
     benefits plan offered by a QHBP offering entity, under the 
     external review process established under this subsection 
     shall be binding on the plan and the entity.
       (d) Time Limits.--The Commissioner shall establish time 
     limits for each of these processes and implement them in a 
     manner that is protective to the patient.
       (e) Construction.--Nothing in this section shall be 
     construed as affecting the availability of judicial review 
     under State law for adverse decisions under subsection (b) or 
     (c), subject to section 251.

     SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND PLAN 
                   DISCLOSURE.

       (a) Accurate and Timely Disclosure.--
       (1) For exchange-participating health benefits plans.--A 
     QHBP offering entity offering an Exchange-participating 
     health benefits plan shall comply with standards established 
     by the Commissioner for the accurate and timely disclosure to 
     the Commissioner and the public of plan documents, plan terms 
     and conditions, claims payment policies and practices, 
     periodic financial disclosure, data on enrollment, data on 
     disenrollment, data on the number of claims denials, data on 
     rating practices, information on cost-sharing and payments 
     with respect to any out-of-network coverage, and other 
     information as determined appropriate by the Commissioner.
       (2) Employment-based health plans.--The Secretary of Labor 
     shall update and harmonize the Secretary's rules concerning 
     the accurate and timely disclosure to participants by group 
     health plans of plan disclosure, plan terms and conditions, 
     and periodic financial disclosure with the standards 
     established by the Commissioner under paragraph (1).
       (3) Use of plain language.--
       (A) In general.--The disclosures under paragraphs (1) and 
     (2) shall be provided in plain language.
       (B) Definition.--In this paragraph, the term ``plain 
     language'' means language that the intended audience, 
     including individuals with limited English proficiency, can 
     readily understand and use because that language is concise, 
     well-organized, and follows other best practices of plain 
     language writing.
       (C) Guidance.--The Commissioner and the Secretary of Labor 
     shall jointly develop and issue guidance on best practices of 
     plain language writing.
       (4) Information on rights.--The information disclosed under 
     this subsection shall include information on enrollee and 
     participant rights under this division.

[[Page 27229]]

       (5) Cost-sharing transparency.--A qualified health benefits 
     plan shall allow individuals to learn the amount of cost-
     sharing (including deductibles, copayments, and coinsurance) 
     under the individual's plan or coverage that the individual 
     would be responsible for paying with respect to the 
     furnishing of a specific item or service by a participating 
     provider in a timely manner upon request. At a minimum, this 
     information shall be made available to such individual via an 
     Internet Website and other means for individuals without 
     access to the Internet.
       (b) Contracting Reimbursement.--A qualified health benefits 
     plan shall comply with standards established by the 
     Commissioner to ensure transparency to each health care 
     provider relating to reimbursement arrangements between such 
     plan and such provider.
       (c) Pharmacy Benefit Managers Transparency Requirements.--
       (1) In general.--If a QHBP offering entity contracts with a 
     pharmacy benefit manager or other entity (in this subsection 
     referred to as a ``PBM'') to manage prescription drug 
     coverage or otherwise control prescription drug costs under a 
     qualified health benefits plan, the PBM shall provide at 
     least annually to the Commissioner and to the QHBP offering 
     entity offering such plan the following information, in a 
     form and manner to be determined by the Commissioner:
       (A) Information on the number and total cost of 
     prescriptions under the contract that are filled via mail 
     order and at retail pharmacies.
       (B) An estimate of aggregate average payments under the 
     contract, per prescription (weighted by prescription volume), 
     made to mail order and retail pharmacies, and the average 
     amount, per prescription, that the PBM was paid by the plan 
     for prescriptions filled at mail order and retail 
     pharmacists.
       (C) An estimate of the aggregate average payment per 
     prescription (weighted by prescription volume) under the 
     contract received from pharmaceutical manufacturers, 
     including all rebates, discounts, prices concessions, or 
     administrative, and other payments from pharmaceutical 
     manufacturers, and a description of the types of payments, 
     and the amount of these payments that were shared with the 
     plan, and a description of the percentage of prescriptions 
     for which the PBM received such payments.
       (D) Information on the overall percentage of generic drugs 
     dispensed under the contract at retail and mail order 
     pharmacies, and the percentage of cases in which a generic 
     drug is dispensed when available.
       (E) Information on the percentage and number of cases under 
     the contract in which individuals were switched because of 
     PBM policies or at the direct or indirect control of the PBM 
     from a prescribed drug that had a lower cost for the QHBP 
     offering entity to a drug that had a higher cost for the QHBP 
     offering entity, the rationale for these switches, and a 
     description of the PBM policies governing such switches.
       (2) Confidentiality of information.--Information disclosed 
     by a PBM to the Commissioner or a QHBP offering entity under 
     this subsection is confidential and shall not be disclosed by 
     the Commissioner or the QHBP offering entity in a form which 
     discloses the identity of a specific PBM or prices charged by 
     such PBM or a specific retailer, manufacturer, or wholesaler, 
     except only by the Commissioner--
       (A) to permit State or Federal law enforcement authorities 
     to use the information provided for program compliance 
     purposes and for the purpose of combating waste, fraud, and 
     abuse;
       (B) to permit the Comptroller General, the Medicare Payment 
     Advisory Commission, or the Secretary of Health and Human 
     Services to review the information provided; and
       (C) to permit the Director of the Congressional Budget 
     Office to review the information provided.
       (3) Annual public report.--On an annual basis, the 
     Commissioner shall prepare a public report providing 
     industrywide aggregate or average information to be used in 
     assessing the overall impact of PBMs on prescription drug 
     prices and spending. Such report shall not disclose the 
     identity of a specific PBM, or prices charged by such PBM, or 
     a specific retailer, manufacturer, or wholesaler, or any 
     other confidential or trade secret information.
       (4) Penalties.--The provisions of subsection (b)(3)(C) of 
     section 1927 shall apply to a PBM that fails to provide 
     information required under subsection (a) or that knowingly 
     provides false information in the same manner as such 
     provisions apply to a manufacturer with an agreement under 
     such section that fails to provide information under 
     subsection (b)(3)(A) of such section or knowingly provides 
     false information under such section, respectively.

     SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT 
                   OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.

       The requirements of the previous provisions of this 
     subtitle shall apply to qualified health benefits plans that 
     are not being offered through the Health Insurance Exchange 
     only to the extent specified by the Commissioner.

     SEC. 235. TIMELY PAYMENT OF CLAIMS.

       A QHBP offering entity shall comply with the requirements 
     of section 1857(f) of the Social Security Act with respect to 
     a qualified health benefits plan it offers in the same manner 
     as a Medicare Advantage organization is required to comply 
     with such requirements with respect to a Medicare Advantage 
     plan it offers under part C of Medicare.

     SEC. 236. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION 
                   OF BENEFITS.

       The Commissioner shall establish standards for the 
     coordination and subrogation of benefits and reimbursement of 
     payments in cases of qualified health benefits plans 
     involving individuals and multiple plan coverage.

     SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

       A QHBP offering entity is required to comply with 
     administrative simplification provisions under part C of 
     title XI of the Social Security Act with respect to qualified 
     health benefits plans it offers.

     SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION AGAINST HEALTH 
                   CARE PROVIDERS.

       This Act (and the amendments made by this Act) shall not be 
     construed as superseding laws, as they now or hereinafter 
     exist, of any State or jurisdiction designed to prohibit a 
     qualified health benefits plan from discriminating with 
     respect to participation, reimbursement, covered services, 
     indemnification, or related requirements under such plan 
     against a health care provider that is acting within the 
     scope of that provider's license or certification under 
     applicable State law.

     SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFORMATION.

       (a) Study.--The Secretary of Health and Human Services 
     shall conduct a study on the use of physician prescriber 
     information in sales and marketing practices of 
     pharmaceutical manufacturers.
       (b) Report.--Based on the study conducted under subsection 
     (a), the Secretary shall submit to Congress a report on 
     actions needed to be taken by the Congress or the Secretary 
     to protect providers from biased marketing and sales 
     practices.

     SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING INFORMATION.

       (a) In General.--The QHBP offering entity --
       (1) shall provide for the dissemination of information 
     related to end-of-life planning to individuals seeking 
     enrollment in Exchange-participating health benefits plans 
     offered through the Exchange;
       (2) shall present such individuals with--
       (A) the option to establish advanced directives and 
     physician's orders for life sustaining treatment according to 
     the laws of the State in which the individual resides; and
       (B) information related to other planning tools; and
       (3) shall not promote suicide, assisted suicide, 
     euthanasia, or mercy killing.
     The information presented under paragraph (2) shall not 
     presume the withdrawal of treatment and shall include end-of-
     life planning information that includes options to maintain 
     all or most medical interventions.
       (b) Construction.-- Nothing in this section shall be 
     construed--
       (1) to require an individual to complete an advanced 
     directive or a physician's order for life sustaining 
     treatment or other end-of-life planning document;
       (2) to require an individual to consent to restrictions on 
     the amount, duration, or scope of medical benefits otherwise 
     covered under a qualified health benefits plan; or
       (3) to promote suicide, assisted suicide, euthanasia, or 
     mercy killing.
       (c) Advanced Directive Defined.--In this section, the term 
     ``advanced directive'' includes a living will, a comfort care 
     order, or a durable power of attorney for health care.
       (d) Prohibition on the Promotion of Assisted Suicide.--
       (1) In general.--Subject to paragraph (3), information 
     provided to meet the requirements of subsection (a)(2) shall 
     not include advanced directives or other planning tools that 
     list or describe as an option suicide, assisted suicide, 
     euthanasia, or mercy killing, regardless of legality.
       (2) Construction.--Nothing in paragraph (1) shall be 
     construed to apply to or affect any option to--
       (A) withhold or withdraw of medical treatment or medical 
     care;
       (B) withhold or withdraw of nutrition or hydration; and
       (C) provide palliative or hospice care or use an item, 
     good, benefit, or service furnished for the purpose of 
     alleviating pain or discomfort, even if such use may increase 
     the risk of death, so long as such item, good, benefit, or 
     service is not also furnished for the purpose of causing, or 
     the purpose of assisting in causing, death, for any reason.
       (3) No preemption of state law.--Nothing in this section 
     shall be construed to preempt or otherwise have any effect on 
     State laws regarding advance care planning, palliative care, 
     or end-of-life decision-making.

                         Subtitle E--Governance

     SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES 
                   COMMISSIONER.

       (a) In General.--There is hereby established, as an 
     independent agency in the executive branch of the Government, 
     a Health

[[Page 27230]]

     Choices Administration (in this division referred to as the 
     ``Administration'').
       (b) Commissioner.--
       (1) In general.--The Administration shall be headed by a 
     Health Choices Commissioner (in this division referred to as 
     the ``Commissioner'') who shall be appointed by the 
     President, by and with the advice and consent of the Senate.
       (2) Compensation; etc.--The provisions of paragraphs (2), 
     (5), and (7) of subsection (a) (relating to compensation, 
     terms, general powers, rulemaking, and delegation) of section 
     702 of the Social Security Act (42 U.S.C. 902) shall apply to 
     the Commissioner and the Administration in the same manner as 
     such provisions apply to the Commissioner of Social Security 
     and the Social Security Administration.
       (c) Inspector General.--For provision establishing an 
     Office of the Inspector General for the Health Choices 
     Administration, see section 1647.

     SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER.

       (a) Duties.--The Commissioner is responsible for carrying 
     out the following functions under this division:
       (1) Qualified plan standards.--The establishment of 
     qualified health benefits plan standards under this title, 
     including the enforcement of such standards in coordination 
     with State insurance regulators and the Secretaries of Labor 
     and the Treasury.
       (2) Health insurance exchange.--The establishment and 
     operation of a Health Insurance Exchange under subtitle A of 
     title III.
       (3) Individual affordability credits.--The administration 
     of individual affordability credits under subtitle C of title 
     III, including determination of eligibility for such credits.
       (4) Additional functions.--Such additional functions as may 
     be specified in this division.
       (b) Promoting Accountability.--
       (1) In general.--The Commissioner shall undertake 
     activities in accordance with this subtitle to promote 
     accountability of QHBP offering entities in meeting Federal 
     health insurance requirements, regardless of whether such 
     accountability is with respect to qualified health benefits 
     plans offered through the Health Insurance Exchange or 
     outside of such Exchange.
       (2) Compliance examination and audits.--
       (A) In general.--The Commissioner shall, in coordination 
     with States, conduct audits of qualified health benefits plan 
     compliance with Federal requirements.   Such audits may 
     include random compliance audits and targeted audits in 
     response to complaints or other suspected noncompliance.
       (B) Recoupment of costs in connection with examination and 
     audits.--The Commissioner is authorized to recoup from 
     qualified health benefits plans reimbursement for the costs 
     of such examinations and audit of such QHBP offering 
     entities.
       (c) Data Collection.--The Commissioner shall collect data 
     for purposes of carrying out the Commissioner's duties, 
     including for purposes of promoting quality and value, 
     protecting consumers, and addressing disparities in health 
     and health care and may share such data with the Secretary of 
     Health and Human Services.
       (d) Sanctions Authority.--
       (1) In general.--In the case that the Commissioner 
     determines that a QHBP offering entity violates a requirement 
     of this title, the Commissioner may, in coordination with 
     State insurance regulators and the Secretary of Labor, 
     provide, in addition to any other remedies authorized by law, 
     for any of the remedies described in paragraph (2).
       (2) Remedies.--The remedies described in this paragraph, 
     with respect to a qualified health benefits plan offered by a 
     QHBP offering entity, are--
       (A) civil money penalties of not more than the amount that 
     would be applicable under similar circumstances for similar 
     violations under section 1857(g) of the Social Security Act;
       (B) suspension of enrollment of individuals under such plan 
     after the date the Commissioner notifies the entity of a 
     determination under paragraph (1) and until the Commissioner 
     is satisfied that the basis for such determination has been 
     corrected and is not likely to recur;
       (C) in the case of an Exchange-participating health 
     benefits plan, suspension of payment to the entity under the 
     Health Insurance Exchange for individuals enrolled in such 
     plan after the date the Commissioner notifies the entity of a 
     determination under paragraph (1) and until the Secretary is 
     satisfied that the basis for such determination has been 
     corrected and is not likely to recur; or
       (D) working with State insurance regulators to terminate 
     plans for repeated failure by the offering entity to meet the 
     requirements of this title.
       (e) Standard Definitions of Insurance and Medical Terms.--
     The Commissioner shall provide for the development of 
     standards for the definitions of terms used in health 
     insurance coverage, including insurance-related terms.
       (f) Efficiency in Administration.--The Commissioner shall 
     issue regulations for the effective and efficient 
     administration of the Health Insurance Exchange and 
     affordability credits under subtitle C, including, with 
     respect to the determination of eligibility for affordability 
     credits, the use of personnel who are employed in accordance 
     with the requirements of title 5, United States Code, to 
     carry out the duties of the Commissioner or, in the case of 
     sections 308 and 341(b)(2), the use of State personnel who 
     are employed in accordance with standards prescribed by the 
     Office of Personnel Management pursuant to section 208 of the 
     Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728).

     SEC. 243. CONSULTATION AND COORDINATION.

       (a) Consultation.--In carrying out the Commissioner's 
     duties under this division, the Commissioner, as appropriate, 
     shall consult at least with the following:
       (1) State attorneys general and State insurance regulators, 
     including concerning the standards for health insurance 
     coverage that is a qualified health benefits plan under this 
     title and enforcement of such standards.
       (2) The National Association of Insurance Commissioners, 
     including for purposes of using model guidelines established 
     by such association for purposes of subtitles B and D.
       (3) Appropriate State agencies, specifically concerning the 
     administration of individual affordability credits under 
     subtitle C of title III and the offering of Exchange-
     participating health benefits plans, to Medicaid eligible 
     individuals under subtitle A of such title.
       (4) The Federal Trade Commission, specifically concerning 
     the development and issuance of guidance, rules, or standards 
     regarding fair marketing practices under section 231 or 
     otherwise, or any consumer disclosure requirements under 
     section 233 or otherwise.
       (5) Other appropriate Federal agencies.
       (6) Indian tribes and tribal organizations.
       (b) Coordination.--
       (1) In general.--In carrying out the functions of the 
     Commissioner, including with respect to the enforcement of 
     the provisions of this division, the Commissioner shall work 
     in coordination with existing Federal and State entities to 
     the maximum extent feasible consistent with this division and 
     in a manner that prevents conflicts of interest in duties and 
     ensures effective enforcement.
       (2) Uniform standards.--The Commissioner, in coordination 
     with such entities, shall seek to achieve uniform standards 
     that adequately protect consumers in a manner that does not 
     unreasonably affect employers and insurers.

     SEC. 244. HEALTH INSURANCE OMBUDSMAN.

       (a) In General.--The Commissioner shall appoint within the 
     Health Choices Administration a Qualified Health Benefits 
     Plan Ombudsman who shall have expertise and experience in the 
     fields of health care and education of (and assistance to) 
     individuals.
       (b) Duties.--The Qualified Health Benefits Plan Ombudsman 
     shall, in a linguistically appropriate manner--
       (1) receive complaints, grievances, and requests for 
     information submitted by individuals through means such as 
     the mail, by telephone, electronically, and in person;
       (2) provide assistance with respect to complaints, 
     grievances, and requests referred to in paragraph (1), 
     including--
       (A) helping individuals determine the relevant information 
     needed to seek an appeal of a decision or determination;
       (B) assistance to such individuals in choosing a qualified 
     health benefits plan in which to enroll;
       (C) assistance to such individuals with any problems 
     arising from disenrollment from such a plan; and
       (D) assistance to such individuals in presenting 
     information under subtitle C (relating to affordability 
     credits); and
       (3) submit annual reports to Congress and the Commissioner 
     that describe the activities of the Ombudsman and that 
     include such recommendations for improvement in the 
     administration of this division as the Ombudsman determines 
     appropriate. The Ombudsman shall not serve as an advocate for 
     any increases in payments or new coverage of services, but 
     may identify issues and problems in payment or coverage 
     policies.

       Subtitle F--Relation to Other Requirements; Miscellaneous

     SEC. 251. RELATION TO OTHER REQUIREMENTS.

       (a) Coverage Not Offered Through Exchange.--
       (1) In general.--In the case of health insurance coverage 
     not offered through the Health Insurance Exchange (whether or 
     not offered in connection with an employment-based health 
     plan), and in the case of employment-based health plans, the 
     requirements of this title do not supercede any requirements 
     applicable under titles XXII and XXVII of the Public Health 
     Service Act, parts 6 and 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974, or State 
     law, except insofar as such requirements prevent the 
     application of a requirement of this division, as determined 
     by the Commissioner.
       (2) Construction.--Nothing in paragraphs (1) or (2) shall 
     be construed as affecting the application of section 514 of 
     the Employee Retirement Income Security Act of 1974.
       (b) Coverage Offered Through Exchange.--
       (1) In general.--In the case of health insurance coverage 
     offered through the Health Insurance Exchange--

[[Page 27231]]

       (A) the requirements of this title do not supercede any 
     requirements (including requirements relating to genetic 
     information nondiscrimination and mental health parity) 
     applicable under title XXVII of the Public Health Service Act 
     or under State law, except insofar as such requirements 
     prevent the application of a requirement of this division, as 
     determined by the Commissioner; and
       (B) individual rights and remedies under State laws shall 
     apply.
       (2) Construction.--In the case of coverage described in 
     paragraph (1), nothing in such paragraph shall be construed 
     as preventing the application of rights and remedies under 
     State laws to health insurance issuers generally with respect 
     to any requirement referred to in paragraph (1)(A). The 
     previous sentence shall not be construed as providing for the 
     applicability of rights or remedies under State laws with 
     respect to requirements applicable to employers or other plan 
     sponsors in connection with arrangements which are treated as 
     group health plans under section 802(a)(1) of the Employee 
     Retirement Income Security Act of 1974.

     SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE.

       (a) In General.--Except as otherwise explicitly permitted 
     by this Act and by subsequent regulations consistent with 
     this Act, all health care and related services (including 
     insurance coverage and public health activities) covered by 
     this Act shall be provided without regard to personal 
     characteristics extraneous to the provision of high quality 
     health care or related services.
       (b) Implementation.--To implement the requirement set forth 
     in subsection (a), the Secretary of Health and Human Services 
     shall, not later than 18 months after the date of the 
     enactment of this Act, promulgate such regulations as are 
     necessary or appropriate to insure that all health care and 
     related services (including insurance coverage and public 
     health activities) covered by this Act are provided (whether 
     directly or through contractual, licensing, or other 
     arrangements) without regard to personal characteristics 
     extraneous to the provision of high quality health care or 
     related services.

     SEC. 253. WHISTLEBLOWER PROTECTION.

       (a) Retaliation Prohibited.--No employer may discharge any 
     employee or otherwise discriminate against any employee with 
     respect to his compensation, terms, conditions, or other 
     privileges of employment because the employee (or any person 
     acting pursuant to a request of the employee)--
       (1) provided, caused to be provided, or is about to provide 
     or cause to be provided to the employer, the Federal 
     Government, or the attorney general of a State information 
     relating to any violation of, or any act or omission the 
     employee reasonably believes to be a violation of any 
     provision of this Act or any order, rule, or regulation 
     promulgated under this Act;
       (2) testified or is about to testify in a proceeding 
     concerning such violation;
       (3) assisted or participated or is about to assist or 
     participate in such a proceeding; or
       (4) objected to, or refused to participate in, any 
     activity, policy, practice, or assigned task that the 
     employee (or other such person) reasonably believed to be in 
     violation of any provision of this Act or any order, rule, or 
     regulation promulgated under this Act.
       (b) Enforcement Action.--An employee covered by this 
     section who alleges discrimination by an employer in 
     violation of subsection (a) may bring an action governed by 
     the rules, procedures, legal burdens of proof, and remedies 
     set forth in section 40(b) of the Consumer Product Safety Act 
     (15 U.S.C. 2087(b)).
       (c) Employer Defined.--As used in this section, the term 
     ``employer'' means any person (including one or more 
     individuals, partnerships, associations, corporations, 
     trusts, professional membership organization including a 
     certification, disciplinary, or other professional body, 
     unincorporated organizations, nongovernmental organizations, 
     or trustees) engaged in profit or nonprofit business or 
     industry whose activities are governed by this Act, and any 
     agent, contractor, subcontractor, grantee, or consultant of 
     such person.
       (d) Rule of Construction.--The rule of construction set 
     forth in section 20109(h) of title 49, United States Code, 
     shall also apply to this section.

     SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

       Nothing in this division shall be construed to alter or 
     supersede any statutory or other obligation to engage in 
     collective bargaining over the terms or conditions of 
     employment related to health care. Any plan amendment made 
     pursuant to a collective bargaining agreement relating to the 
     plan which amends the plan solely to conform to any 
     requirement added by this division shall not be treated as a 
     termination of such collective bargaining agreement.

     SEC. 255. SEVERABILITY.

       If any provision of this Act, or any application of such 
     provision to any person or circumstance, is held to be 
     unconstitutional, the remainder of the provisions of this Act 
     and the application of the provision to any other person or 
     circumstance shall not be affected.

     SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE ACT.

       (a) In General.--Subject to this section--
       (1) nothing in this division (or an amendment made by this 
     division) shall be construed to modify or limit the 
     application of the exemption for the Hawaii Prepaid Health 
     Care Act (Haw. Rev. Stat. Sec. Sec.  393-1 et seq.) as 
     provided for under section 514(b)(5) of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 
     1144(b)(5)), and such exemption shall also apply with respect 
     to the provisions of this division; and
       (2) for purposes of this division (and the amendments made 
     by this division), coverage provided pursuant to the Hawaii 
     Prepaid Health Care Act shall be treated as a qualified 
     health benefits plan providing acceptable coverage so long as 
     the Secretary of Labor determines that such coverage for 
     employees (taking into account the benefits and the cost to 
     employees for such benefits) is substantially equivalent to 
     or greater than the coverage provided for employees pursuant 
     to the essential benefits package.
       (b) Coordination With State Law of Hawaii.--The 
     Commissioner shall, based on ongoing consultation with the 
     appropriate officials of the State of Hawaii, make 
     adjustments to rules and regulations of the Commissioner 
     under this division as may be necessary, as determined by the 
     Commissioner, to most effectively coordinate the provisions 
     of this division with the provisions of the Hawaii Prepaid 
     Health Care Act, taking into account any changes made from 
     time to time to the Hawaii Prepaid Health Care Act and 
     related laws of such State.

     SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL.

       Any State attorney general may bring a civil action in the 
     name of such State as parens patriae on behalf of natural 
     persons residing in such State, in any district court of the 
     United States or State court having jurisdiction of the 
     defendant to secure monetary or equitable relief for 
     violation of any provisions of this title or regulations 
     issued thereunder. Nothing in this section shall be construed 
     as affecting the application of section 514 of the Employee 
     Retirement Income Security Act of 1974.

     SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS REGARDING 
                   ABORTION.

       (a) No Preemption of State Laws Regarding Abortion.--
     Nothing in this Act shall be construed to preempt or 
     otherwise have any effect on State laws regarding the 
     prohibition of (or requirement of) coverage, funding, or 
     procedural requirements on abortions, including parental 
     notification or consent for the performance of an abortion on 
     a minor.
       (b) No Effect on Federal Laws Regarding Abortion.--
       (1) In general.--Nothing in this Act shall be construed to 
     have any effect on Federal laws regarding--
       (A) conscience protection;
       (B) willingness or refusal to provide abortion; and
       (C) discrimination on the basis of the willingness or 
     refusal to provide, pay for, cover, or refer for abortion or 
     to provide or participate in training to provide abortion.
       (c) No Effect on Federal Civil Rights Law.--Nothing in this 
     section shall alter the rights and obligations of employees 
     and employers under title VII of the Civil Rights Act of 
     1964.

     SEC. 259. NONDISCRIMINATION ON ABORTION AND RESPECT FOR 
                   RIGHTS OF CONSCIENCE.

        (a) Nondiscrimination.--A Federal agency or program, and 
     any State or local government that receives Federal financial 
     assistance under this Act (or an amendment made by this Act), 
     may not--
       (1) subject any individual or institutional health care 
     entity to discrimination; or
       (2) require any health plan created or regulated under this 
     Act (or an amendment made by this Act) to subject any 
     individual or institutional health care entity to 
     discrimination,

     on the basis that the health care entity does not provide, 
     pay for, provide coverage of, or refer for abortions.
       (b) Definition.--In this section, the term ``health care 
     entity'' includes an individual physician or other health 
     care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, or any other kind of health care facility, 
     organization, or plan.
       (c) Administration.--The Office for Civil Rights of the 
     Department of Health and Human Services is designated to 
     receive complaints of discrimination based on this section, 
     and coordinate the investigation of such complaints.

     SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION.

       Section 6 of the Federal Trade Commission Act (15 U.S.C. 
     46) is amended by striking ``and prepare reports'' and all 
     that follows and inserting the following: ``and prepare 
     reports, and to share information under clauses (f) and (k), 
     relating to insurance. Notwithstanding section 4, the 
     Commission's authority shall include the authority to conduct 
     studies and prepare reports, and to share information under 
     clauses (f) and (k), relating to insurance, without regard to 
     whether the subject of such studies, reports, or information 
     is for-profit or not-for-profit entity.''.

[[Page 27232]]



     SEC. 261. CONSTRUCTION REGARDING STANDARD OF CARE.

       (a) In General.--The development, recognition, or 
     implementation of any guideline or other standard under a 
     provision described in subsection (b) shall not be construed 
     to establish the standard of care or duty of care owed by 
     health care providers to their patients in any medical 
     malpractice action or claim (as defined in section 431(7) of 
     the Health Care Quality Improvement Act of 1986 (42 U.S.C. 
     11151(7)).
       (b) Provisions Described.--The provisions described in this 
     subsection are the following:
       (1) Section 324 (relating to modernized payment initiatives 
     and delivery system reform under the public health option).
       (2) The amendments made by section 1151 (relating to 
     reducing potentially preventable hospital readmissions).
       (3) The amendments made by section 1751 (relating to health 
     care acquired conditions).
       (4) Section 3131 of the Public Health Service Act (relating 
     to the Task Force on Clinical Preventive Services), added by 
     section 2301.
       (5) Part D of title IX of the Public Health Service Act 
     (relating to implementation of best practices in the delivery 
     of health care), added by section 2401.
       (c) Savings Clause for State Medical Mal-practice Laws.--
     Nothing in this Act or the amendments made by this Act shall 
     be construed to modify or impair State law governing legal 
     standards or procedures used in medical malpractice cases, 
     including the authority of a State to make or implement such 
     laws.

     SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS TO HEALTH 
                   SECTOR INSURERS.

       (a) Amendment to McCarran-Ferguson Act.--Section 3 of the 
     Act of March 9, 1945 (15 U.S.C. 1013), commonly known as the 
     McCarran-Ferguson Act, is amended by adding at the end the 
     following:
       ``(c)(1) Except as provided in paragraph (2), nothing 
     contained in this Act shall modify, impair, or supersede the 
     operation of any of the antitrust laws with respect to the 
     business of health insurance or the business of medical 
     malpractice insurance.
       ``(2) Paragraph (1) shall not apply to--
       ``(A) collecting, compiling, classifying, or disseminating 
     historical loss data;
       ``(B) determining a loss development factor applicable to 
     historical loss data; or
       ``(C) performing actuarial services if doing so does not 
     involve a restraint of trade.
       ``(3) For purposes of this subsection--
       ``(A) the term `antitrust laws' has the meaning given it in 
     subsection (a) of the first section of the Clayton Act, 
     except that such term includes section 5 of the Federal Trade 
     Commission Act to the extent that such section 5 applies to 
     unfair methods of competition;
       ``(B) the term `historical loss data' means information 
     respecting claims paid, or reserves held for claims reported, 
     by any person engaged in the business of insurance; and
       ``(C) the term `loss development factor' means an 
     adjustment to be made to the aggregate of losses incurred 
     during a prior period of time that have been paid, or for 
     which claims have been received and reserves are being held, 
     in order to estimate the aggregate of the losses incurred 
     during such period that will ultimately be paid.''.
       (b) Related Provision.--For purposes of section 5 of the 
     Federal Trade Commission Act (15 U.S.C. 45) to the extent 
     such section applies to unfair methods of competition, 
     section 3(c) of the McCarran-Ferguson Act shall apply with 
     respect to the business of health insurance, and with respect 
     to the business of medical malpractice insurance, without 
     regard to whether such business is carried on for profit, 
     notwithstanding the definition of ``Corporation'' contained 
     in section 4 of the Federal Trade Commission Act.
       (c) Related Preservation of Antitrust Laws.--Except as 
     provided in subsections (a) and (b), nothing in this Act, or 
     in the amendments made by this Act, shall be construed to 
     modify, impair, or supersede the operation of any of the 
     antitrust laws. For purposes of the preceding sentence, the 
     term ``antitrust laws'' has the meaning given it in 
     subsection (a) of the first section of the Clayton Act, 
     except that it includes section 5 of the Federal Trade 
     Commission Act to the extent that such section 5 applies to 
     unfair methods of competition.

     SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE EHR USE BY 
                   SMALL HEALTH CARE PROVIDERS.

       (a) Study.--The Secretary of Health and Human Services 
     shall conduct a study of potential methods to increase the 
     use of qualified electronic health records (as defined in 
     section 3000(13) of the Public Health Service Act) by small 
     health care providers. Such study shall consider at least the 
     following methods:
       (1) Providing for higher rates of reimbursement or other 
     incentives for such health care providers to use electronic 
     health records (taking into consideration initiatives by 
     private health insurance companies and incentives provided 
     under Medicare under title XVIII of the Social Security Act, 
     Medicaid under title XIX of such Act, and other programs).
       (2) Promoting low-cost electronic health record software 
     packages that are available for use by such health care 
     providers, including software packages that are available to 
     health care providers through the Veterans Administration and 
     other sources.
       (3) Training and education of such health care providers on 
     the use of electronic health records.
       (4) Providing assistance to such health care providers on 
     the implementation of electronic health records.
       (b) Report.--Not later than December 31, 2013, the 
     Secretary of Health and Human Services shall submit to 
     Congress a report containing the results of the study 
     conducted under subsection (a), including recommendations for 
     legislation or administrative action to increase the use of 
     electronic health records by small health care providers that 
     include the use of both public and private funding sources.

     SEC. 264. PREFORMANCE ASSESSMENT AND ACCOUNTABILITY: 
                   APPLICATION OF GPRA.

       (a) Application of GPRA.--Section 306 of title 5, United 
     States Code, and sections 1115, 1116, 1117, and 9703 of title 
     31 of such Code (originally enacted by the Government 
     Performance and Results Act of 1993, Public Law 103-62) apply 
     to the executive agencies established by this Act, including 
     the Health Choices Administration. Under such section 306, 
     each such executive agency is required to provide for a 
     strategic plan every 3 years.
       (b) Improving Consumer Service and Streamlining 
     Procedures.--Every 3 years each such executive agency shall--
       (1)(A) assess the quality of customer service provided, (B) 
     develop a strategy for improving such service, and (C) 
     establish standards for high-quality customer service; and
       (2)(A) identify redundant rules, regulations, and 
     procedures, and (B) develop and implement a plan for 
     eliminating or streamlining such redundancies.

      TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

                 Subtitle A--Health Insurance Exchange

     SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE 
                   OF DUTIES; DEFINITIONS.

       (a) Establishment.--There is established within the Health 
     Choices Administration and under the direction of the 
     Commissioner a Health Insurance Exchange in order to 
     facilitate access of individuals and employers, through a 
     transparent process, to a variety of choices of affordable, 
     quality health insurance coverage, including a public health 
     insurance option.
       (b) Outline of Duties of Commissioner.--In accordance with 
     this subtitle and in coordination with appropriate Federal 
     and State officials as provided under section 243(b), the 
     Commissioner shall--
       (1) under section 304 establish standards for, accept bids 
     from, and negotiate and enter into contracts with, QHBP 
     offering entities for the offering of health benefits plans 
     through the Health Insurance Exchange, with different levels 
     of benefits required under section 303, and including with 
     respect to oversight and enforcement;
       (2) under section 305 facilitate outreach and enrollment in 
     such plans of Exchange-eligible individuals and employers 
     described in section 302; and
       (3) conduct such activities related to the Health Insurance 
     Exchange as required, including establishment of a risk 
     pooling mechanism under section 306 and consumer protections 
     under subtitle D of title II.

     SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

       (a) Access to Coverage.--In accordance with this section, 
     all individuals are eligible to obtain coverage through 
     enrollment in an Exchange-participating health benefits plan 
     offered through the Health Insurance Exchange unless such 
     individuals are enrolled in another qualified health benefits 
     plan or certain other acceptable coverage.
       (b) Definitions.--In this division:
       (1) Exchange-eligible individual.--The term ``Exchange-
     eligible individual'' means an individual who is eligible 
     under this section to be enrolled through the Health 
     Insurance Exchange in an Exchange-participating health 
     benefits plan and, with respect to family coverage, includes 
     dependents of such individual.
       (2) Exchange-eligible employer.--The term ``Exchange-
     eligible employer'' means an employer that is eligible under 
     this section to enroll through the Health Insurance Exchange 
     employees of the employer (and their dependents) in Exchange-
     eligible health benefits plans.
       (3) Employment-related definitions.--The terms 
     ``employer'', ``employee'', ``full-time employee'', and 
     ``part-time employee'' have the meanings given such terms by 
     the Commissioner for purposes of this division.
       (c) Transition.--Individuals and employers shall only be 
     eligible to enroll or participate in the Health Insurance 
     Exchange in accordance with the following transition 
     schedule:
       (1) First year.--In Y1 (as defined in section 100(c))--
       (A) individuals described in subsection (d)(1), including 
     individuals described in subsection (d)(3); and
       (B) smallest employers described in subsection (e)(1).
       (2) Second year.--In Y2--
       (A) individuals and employers described in paragraph (1); 
     and

[[Page 27233]]

       (B) smaller employers described in subsection (e)(2).
       (3) Third and subsequent years.--In Y3--
       (A) individuals and employers described in paragraph (2);
       (B) small employers described in subsection (e)(3); and
       (C) larger employers as permitted by the Commissioner under 
     subsection (e)(4).
       (d) Individuals.--
       (1) Individual described.--Subject to the succeeding 
     provisions of this subsection, an individual described in 
     this paragraph is an individual who--
       (A) is not enrolled in coverage described in subparagraph 
     (C) or (D) of paragraph (2); and
       (B) is not enrolled in coverage as a full-time employee (or 
     as a dependent of such an employee) under a group health plan 
     if the coverage and an employer contribution under the plan 
     meet the requirements of section 412.

     For purposes of subparagraph (B), in the case of an 
     individual who is self-employed, who has at least 1 employee, 
     and who meets the requirements of section 412, such 
     individual shall be deemed a full-time employee described in 
     such subparagraph.
       (2) Acceptable coverage.--For purposes of this division, 
     the term ``acceptable coverage'' means any of the following:
       (A) Qualified health benefits plan coverage.--Coverage 
     under a qualified health benefits plan.
       (B) Grandfathered health insurance coverage; coverage under 
     current group health plan.--Coverage under a grandfathered 
     health insurance coverage (as defined in subsection (a) of 
     section 202) or under a current group health plan (described 
     in subsection (b) of such section).
       (C) Medicare.--Coverage under part A of title XVIII of the 
     Social Security Act.
       (D) Medicaid.--Coverage for medical assistance under title 
     XIX of the Social Security Act, excluding such coverage that 
     is only available because of the application of subsection 
     (u), (z), or (aa), or (hh) of section 1902 of such Act.
       (E) Members of the armed forces and dependents (including 
     tricare).--Coverage under chapter 55 of title 10, United 
     States Code, including similar coverage furnished under 
     section 1781 of title 38 of such Code.
       (F) VA.--Coverage under the veteran's health care program 
     under chapter 17 of title 38, United States Code.
       (G) Other coverage.--Such other health benefits coverage, 
     such as a State health benefits risk pool, as the 
     Commissioner, in coordination with the Secretary of the 
     Treasury, recognizes for purposes of this paragraph.

     The Commissioner shall make determinations under this 
     paragraph in coordination with the Secretary of the Treasury.
       (3) Continuing eligibility permitted.--
       (A) In general.--Except as provided in subparagraph (B), 
     once an individual qualifies as an Exchange-eligible 
     individual under this subsection (including as an employee or 
     dependent of an employee of an Exchange-eligible employer) 
     and enrolls under an Exchange-participating health benefits 
     plan through the Health Insurance Exchange, the individual 
     shall continue to be treated as an Exchange-eligible 
     individual until the individual is no longer enrolled with an 
     Exchange-participating health benefits plan.
       (B) Exceptions.--
       (i) In general.--Subparagraph (A) shall not apply to an 
     individual once the individual becomes eligible for 
     coverage--

       (I) under part A of the Medicare program;
       (II) under the Medicaid program as a Medicaid-eligible 
     individual, except as permitted under clause (ii); or
       (III) in such other circumstances as the Commissioner may 
     provide.

       (ii) Transition period.--In the case described in clause 
     (i)(II), the Commissioner shall permit the individual to 
     continue treatment under subparagraph (A) until such limited 
     time as the Commissioner determines it is administratively 
     feasible, consistent with minimizing disruption in the 
     individual's access to health care.
       (4) Transition for chip eligibles.--An individual who is 
     eligible for child health assistance under title XXI of the 
     Social Security Act for a period during Y1 shall not be an 
     Exchange-eligible individual during such period.
       (e) Employers.--
       (1) Smallest employer.--Subject to paragraph (5), smallest 
     employers described in this paragraph are employers with 25 
     or fewer employees.
       (2) Smaller employers.--Subject to paragraph (5), smaller 
     employers described in this paragraph are employers that are 
     not smallest employers described in paragraph (1) and have 50 
     or fewer employees.
       (3) Small employers.--Subject to paragraph (5), small 
     employers described in this paragraph are employers that are 
     not described in paragraph (1) or (2) and have 100 or fewer 
     employees.
       (4) Larger employers.--
       (A) In general.--Beginning with Y3, the Commissioner may 
     permit employers not described in paragraph (1), (2), or (3) 
     to be Exchange-eligible employers.
       (B) Phase-in.--In applying subparagraph (A), the 
     Commissioner may phase-in the application of such 
     subparagraph based on the number of full-time employees of an 
     employer and such other considerations as the Commissioner 
     deems appropriate.
       (5) Continuing eligibility.--Once an employer is permitted 
     to be an Exchange-eligible employer under this subsection and 
     enrolls employees through the Health Insurance Exchange, the 
     employer shall continue to be treated as an Exchange-eligible 
     employer for each subsequent plan year regardless of the 
     number of employees involved unless and until the employer 
     meets the requirement of section 411(a) through paragraph (1) 
     of such section by offering a group health plan and not 
     through offering an Exchange-participating health benefits 
     plan.
       (6) Employer participation and contributions.--
       (A) Satisfaction of employer responsibility.--For any year 
     in which an employer is an Exchange-eligible employer, such 
     employer may meet the requirements of section 412 with 
     respect to employees of such employer by offering such 
     employees the option of enrolling with Exchange-participating 
     health benefits plans through the Health Insurance Exchange 
     consistent with the provisions of subtitle B of title IV.
       (B) Employee choice.--Any employee offered Exchange-
     participating health benefits plans by the employer of such 
     employee under subparagraph (A) may choose coverage under any 
     such plan. That choice includes, with respect to family 
     coverage, coverage of the dependents of such employee.
       (7) Affiliated groups.--Any employer which is part of a 
     group of employers who are treated as a single employer under 
     subsection (b), (c), (m), or (o) of section 414 of the 
     Internal Revenue Code of 1986 shall be treated, for purposes 
     of this subtitle, as a single employer.
       (8) Treatment of multi-employer plans.--The plan sponsor of 
     a group health plan (as defined in section 773(a) of the 
     Employee Retirement Income Security Act of 1974) that is a 
     multi-employer plan (as defined in section 3(37) of such Act) 
     may obtain health insurance coverage with respect to 
     participants in the plan through the Exchange to the same 
     extent that an employer not described in paragraph (1) or (2) 
     is permitted by the Commissioner to obtain health insurance 
     coverage through the Exchange as an Exchange-eligible 
     employer.
       (9) Other counting rules.--The Commissioner shall establish 
     rules relating to how employees are counted for purposes of 
     carrying out this subsection.
       (f) Special Situation Authority.--The Commissioner shall 
     have the authority to establish such rules as may be 
     necessary to deal with special situations with regard to 
     uninsured individuals and employers participating as 
     Exchange-eligible individuals and employers, such as 
     transition periods for individuals and employers who gain, or 
     lose, Exchange-eligible participation status, and to 
     establish grace periods for premium payment.
       (g) Surveys of Individuals and Employers.--The Commissioner 
     shall provide for periodic surveys of Exchange-eligible 
     individuals and employers concerning satisfaction of such 
     individuals and employers with the Health Insurance Exchange 
     and Exchange-participating health benefits plans.
       (h) Exchange Access Study.--
       (1) In general.--The Commissioner shall conduct a study of 
     access to the Health Insurance Exchange for individuals and 
     for employers, including individuals and employers who are 
     not eligible and enrolled in Exchange-participating health 
     benefits plans. The goal of the study is to determine if 
     there are significant groups and types of individuals and 
     employers who are not Exchange-eligible individuals or 
     employers, but who would have improved benefits and 
     affordability if made eligible for coverage in the Exchange.
       (2) Items included in study.--Such study also shall 
     examine--
       (A) the terms, conditions, and affordability of group 
     health coverage offered by employers and QHBP offering 
     entities outside of the Exchange compared to Exchange-
     participating health benefits plans; and
       (B) the affordability-test standard for access of certain 
     employed individuals to coverage in the Health Insurance 
     Exchange.
       (3) Report.--Not later than January 1 of Y3, in Y6, and 
     thereafter, the Commissioner shall submit to Congress a 
     report on the study conducted under this subsection and shall 
     include in such report recommendations regarding changes in 
     standards for Exchange eligibility for individuals and 
     employers.

     SEC. 303. BENEFITS PACKAGE LEVELS.

       (a) In General.--The Commissioner shall specify the 
     benefits to be made available under Exchange-participating 
     health benefits plans during each plan year, consistent with 
     subtitle C of title II and this section.
       (b) Limitation on Health Benefits Plans Offered by Offering 
     Entities.--The Commissioner may not enter into a contract 
     with a QHBP offering entity under section 304(c) for the 
     offering of an Exchange-participating health benefits plan in 
     a service area unless the following requirements are met:
       (1) Required offering of basic plan.--The entity offers 
     only one basic plan for such service area.
       (2) Optional offering of enhanced plan.--If and only if the 
     entity offers a basic

[[Page 27234]]

     plan for such service area, the entity may offer one enhanced 
     plan for such area.
       (3) Optional offering of premium plan.--If and only if the 
     entity offers an enhanced plan for such service area, the 
     entity may offer one premium plan for such area.
       (4) Optional offering of premium-plus plans.--If and only 
     if the entity offers a premium plan for such service area, 
     the entity may offer one or more premium-plus plans for such 
     area.
     All such plans may be offered under a single contract with 
     the Commissioner.
       (c) Specification of Benefit Levels for Plans.--
       (1) In general.--The Commissioner shall establish the 
     following standards consistent with this subsection and title 
     II:
       (A) Basic, enhanced, and premium plans.--Standards for 3 
     levels of Exchange-participating health benefits plans: 
     basic, enhanced, and premium (in this division referred to as 
     a ``basic plan'', ``enhanced plan'', and ``premium plan'', 
     respectively).
       (B) Premium-plus plan benefits.--Standards for additional 
     benefits that may be offered, consistent with this subsection 
     and subtitle C of title II, under a premium plan (such a plan 
     with additional benefits referred to in this division as a 
     ``premium-plus 
     plan'').
       (2) Basic plan.--
       (A) In general.--A basic plan shall offer the essential 
     benefits package required under title II for a qualified 
     health benefits plan with an actuarial value of 70 percent of 
     the full actuarial value of the benefits provided under the 
     reference benefits package.
       (B) Tiered cost-sharing for affordable credit eligible 
     individuals.--In the case of an affordable credit eligible 
     individual (as defined in section 342(a)(1)) enrolled in an 
     Exchange-participating health benefits plan, the benefits 
     under a basic plan are modified to provide for the reduced 
     cost-sharing for the income tier applicable to the individual 
     under section 324(c).
       (3) Enhanced plan.--An enhanced plan shall offer, in 
     addition to the level of benefits under the basic plan, a 
     lower level of cost-sharing as provided under title II 
     consistent with section 223(b)(5)(A).
       (4) Premium plan.--A premium plan shall offer, in addition 
     to the level of benefits under the basic plan, a lower level 
     of cost-sharing as provided under title II consistent with 
     section 223(b)(5)(B).
       (5) Premium-plus plan.--A premium-plus plan is a premium 
     plan that also provides additional benefits, such as adult 
     oral health and vision care, approved by the Commissioner. 
     The portion of the premium that is attributable to such 
     additional benefits shall be separately specified.
       (6) Range of permissible variation in cost-sharing.--The 
     Commissioner shall establish a permissible range of variation 
     of cost-sharing for each basic, enhanced, and premium plan, 
     except with respect to any benefit for which there is no 
     cost-sharing permitted under the essential benefits package. 
     Such variation shall permit a variation of not more than plus 
     (or minus) 10 percent in cost-sharing with respect to each 
     benefit category specified under section 222. Nothing in this 
     subtitle shall be construed as prohibiting tiering in cost-
     sharing, including through preferred and participating 
     providers and prescription drugs. In applying this paragraph, 
     a health benefits plan may increase the cost-sharing by 10 
     percent within each category or tier, as applicable, and may 
     decrease or eliminate cost-sharing in any category or tier as 
     compared to the essential benefits package.
       (d) Treatment of State Benefit Mandates.--Insofar as a 
     State requires a health insurance issuer offering health 
     insurance coverage to include benefits beyond the essential 
     benefits package, such requirement shall continue to apply to 
     an Exchange-participating health benefits plan, if the State 
     has entered into an arrangement satisfactory to the 
     Commissioner to reimburse the Commissioner for the amount of 
     any net increase in affordability premium credits under 
     subtitle C as a result of an increase in premium in basic 
     plans as a result of application of such requirement.
       (e) Rules Regarding Coverage of and Affordability Credits 
     for Specified Services.--
       (1) Assured availability of varied coverage through the 
     health insurance exchange.--The Commissioner shall assure 
     that, of the Exchange participating health benefits plans 
     offered in each premium rating area of the Health Insurance 
     Exchange--
       (A) there is at least one such plan that provides coverage 
     of services described in subparagraphs (A) and (B) of section 
     222(e)(4); and
       (B) there is at least one such plan that does not provide 
     coverage of services described in section 222(e)(4)(A) which 
     plan may also be one that does not provide coverage of 
     services described in section 222(e)(4)(B).
       (2) Segregation of funds.--If a qualified health benefits 
     plan provides coverage of services described in section 
     222(e)(4)(A), the plan shall provide assurances satisfactory 
     to the Commissioner that--
       (A) any affordability credits provided under subtitle C of 
     title II are not used for purposes of paying for such 
     services; and
       (B) only premium amounts attributable to the actuarial 
     value described in section 213(b) are used for such purpose.

     SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE-
                   PARTICIPATING HEALTH BENEFITS PLANS.

       (a) Contracting Duties.--In carrying out section 301(b)(1) 
     and consistent with this subtitle:
       (1) Offering entity and plan standards.--The Commissioner 
     shall--
       (A) establish standards necessary to implement the 
     requirements of this title and title II for--
       (i) QHBP offering entities for the offering of an Exchange-
     participating health benefits plan; and
       (ii) Exchange-participating health benefits plans; and
       (B) certify QHBP offering entities and qualified health 
     benefits plans as meeting such standards and requirements of 
     this title and title II for purposes of this subtitle.
       (2) Soliciting and negotiating bids; contracts.--
       (A) Bid solicitation.--The Commissioner shall solicit bids 
     from QHBP offering entities for the offering of Exchange-
     participating health benefits plans. Such bids shall include 
     justification for proposed premiums.
       (B) Bid review and negotiation.--The Commissioner shall, 
     based upon a review of such bids including the premiums and 
     their affordability, negotiate with such entities for the 
     offering of such plans.
       (C) Denial of excessive premiums.--The Commissioner shall 
     deny excessive premiums and premium increases.
       (D) Contracts.--The Commissioner shall enter into contracts 
     with such entities for the offering of such plans through the 
     Health Insurance Exchange under terms (consistent with this 
     title) negotiated between the Commissioner and such entities.
       (3) Federal acquisition regulation.--In carrying out this 
     subtitle, the Commissioner may waive such provisions of the 
     Federal Acquisition Regulation that the Commissioner 
     determines to be inconsistent with the furtherance of this 
     subtitle, other than provisions relating to confidentiality 
     of information. Competitive procedures shall be used in 
     awarding contracts under this subtitle to the extent that 
     such procedures are consistent with this subtitle.
       (b) Standards for QHBP Offering Entities To Offer Exchange-
     Participating Health Benefits Plans.--The standards 
     established under subsection (a)(1)(A) shall require that, in 
     order for a QHBP offering entity to offer an Exchange-
     participating health benefits plan, the entity must meet the 
     following requirements:
       (1) Licensed.--The entity shall be licensed to offer health 
     insurance coverage under State law for each State in which it 
     is offering such coverage.
       (2) Data reporting.--The entity shall provide for the 
     reporting of such information as the Commissioner may 
     specify, including information necessary to administer the 
     risk pooling mechanism described in section 306(b) and 
     information to address disparities in health and health care.
       (3) Affordability.--The entity shall provide for affordable 
     premiums.
       (4) Implementing affordability credits.--The entity shall 
     provide for implementation of the affordability credits 
     provided for enrollees under subtitle C, including the 
     reduction in cost-sharing under section 344(c).
       (5) Enrollment.--The entity shall accept all enrollments 
     under this subtitle, subject to such exceptions (such as 
     capacity limitations) in accordance with the requirements 
     under title II for a qualified health benefits plan. The 
     entity shall notify the Commissioner if the entity projects 
     or anticipates reaching such a capacity limitation that would 
     result in a limitation in enrollment.
       (6) Risk pooling participation.--The entity shall 
     participate in such risk pooling mechanism as the 
     Commissioner establishes under section 306(b).
       (7) Essential community providers.--With respect to the 
     basic plan offered by the entity, the entity shall include 
     within the plan network those essential community providers, 
     where available, that serve predominantly low-income, 
     medically-underserved individuals, such as health care 
     providers defined in section 340B(a)(4) of the Public Health 
     Service Act and providers described in section 
     1927(c)(1)(D)(i)(IV) of the Social Security Act (as amended 
     by section 221 of Public Law 111-8). The Commissioner shall 
     specify the extent to which and manner in which the previous 
     sentence shall apply in the case of a basic plan with respect 
     to which the Commissioner determines provides substantially 
     all benefits through a health maintenance organization, as 
     defined in section 2791(b)(3) of the Public Health Service 
     Act. This paragraph shall not be construed to require a basic 
     plan to contract with a provider if such provider refuses to 
     accept the generally applicable payment rates of such plan.
       (8) Culturally and linguistically appropriate services and 
     communications.--The entity shall provide for culturally and 
     linguistically appropriate communication and health services.
       (9) Special rules with respect to indian enrollees and 
     indian health care providers.--
       (A) Choice of providers.--The entity shall--

[[Page 27235]]

       (i) demonstrate to the satisfaction of the Commissioner 
     that it has contracted with a sufficient number of Indian 
     health care providers to ensure timely access to covered 
     services furnished by such providers to individual Indians 
     through the entity's Exchange-participating health benefits 
     plan; and
       (ii) agree to pay Indian health care providers, whether 
     such providers are participating or nonparticipating 
     providers with respect to the entity, for covered services 
     provided to those enrollees who are eligible to receive 
     services from such providers at a rate that is not less than 
     the level and amount of payment which the entity would make 
     for the services of a participating provider which is not an 
     Indian health care provider.
       (B) Special rule relating to indian health care 
     providers.--Provision of services by an Indian health care 
     provider exclusively to Indians and their dependents shall 
     not constitute discrimination under this Act.
       (10) Program integrity standards.--The entity shall 
     establish and operate a program to protect and promote the 
     integrity of Exchange-participating health benefits plans it 
     offers, in accordance with standards and functions 
     established by the Commissioner.
       (11) Additional requirements.--The entity shall comply with 
     other applicable requirements of this title, as specified by 
     the Commissioner, which shall include standards regarding 
     billing and collection practices for premiums and related 
     grace periods and which may include standards to ensure that 
     the entity does not use coercive practices to force providers 
     not to contract with other entities offering coverage through 
     the Health Insurance Exchange.
       (c) Contracts.--
       (1) Bid application.--To be eligible to enter into a 
     contract under this section, a QHBP offering entity shall 
     submit to the Commissioner a bid at such time, in such 
     manner, and containing such information as the Commissioner 
     may require.
       (2) Term.--Each contract with a QHBP offering entity under 
     this section shall be for a term of not less than one year, 
     but may be made automatically renewable from term to term in 
     the absence of notice of termination by either party.
       (3) Enforcement of network adequacy.--In the case of a 
     health benefits plan of a QHBP offering entity that uses a 
     provider network, the contract under this section with the 
     entity shall provide that if--
       (A) the Commissioner determines that such provider network 
     does not meet such standards as the Commissioner shall 
     establish under section 215; and
       (B) an individual enrolled in such plan receives an item or 
     service from a provider that is not within such network;
     then any cost-sharing for such item or service shall be equal 
     to the amount of such cost-sharing that would be imposed if 
     such item or service was furnished by a provider within such 
     network.
       (4) Oversight and enforcement responsibilities.--The 
     Commissioner shall establish processes, in coordination with 
     State insurance regulators, to oversee, monitor, and enforce 
     applicable requirements of this title with respect to QHBP 
     offering entities offering Exchange-participating health 
     benefits plans, including the marketing of such plans. Such 
     processes shall include the following:
       (A) Grievance and complaint mechanisms.--The Commissioner 
     shall establish, in coordination with State insurance 
     regulators, a process under which Exchange-eligible 
     individuals and employers may file complaints concerning 
     violations of such standards.
       (B) Enforcement.--In carrying out authorities under this 
     division relating to the Health Insurance Exchange, the 
     Commissioner may impose one or more of the intermediate 
     sanctions described in section 242(d).
       (C) Termination.--
       (i) In general.--The Commissioner may terminate a contract 
     with a QHBP offering entity under this section for the 
     offering of an Exchange-participating health benefits plan if 
     such entity fails to comply with the applicable requirements 
     of this title. Any determination by the Commissioner to 
     terminate a contract shall be made in accordance with formal 
     investigation and compliance procedures established by the 
     Commissioner under which--

       (I) the Commissioner provides the entity with the 
     reasonable opportunity to develop and implement a corrective 
     action plan to correct the deficiencies that were the basis 
     of the Commissioner's determination; and
       (II) the Commissioner provides the entity with reasonable 
     notice and opportunity for hearing (including the right to 
     appeal an initial decision) before terminating the contract.

       (ii) Exception for imminent and serious risk to health.--
     Clause (i) shall not apply if the Commissioner determines 
     that a delay in termination, resulting from compliance with 
     the procedures specified in such clause prior to termination, 
     would pose an imminent and serious risk to the health of 
     individuals enrolled under the qualified health benefits plan 
     of the QHBP offering entity.
       (D) Construction.--Nothing in this subsection shall be 
     construed as preventing the application of other sanctions 
     under subtitle E of title II with respect to an entity for a 
     violation of such a requirement.
       (5) Special rule related to cost-sharing and indian health 
     care providers.--The contract under this section with a QHBP 
     offering entity for a health benefits plan shall provide that 
     if an individual who is an Indian is enrolled in such a plan 
     and such individual receives a covered item or service from 
     an Indian health care provider (regardless of whether such 
     provider is in the plan's provider network), the cost-sharing 
     for such item or service shall be equal to the amount of 
     cost-sharing that would be imposed if such item or service--
       (A) had been furnished by another provider in the plan's 
     provider network; or
       (B) in the case that the plan has no such network, was 
     furnished by a non-Indian provider.
       (6) National plan.--Nothing in this section shall be 
     construed as preventing the Commissioner from entering into a 
     contract under this subsection with a QHBP offering entity 
     for the offering of a health benefits plan with the same 
     benefits in every State so long as such entity is licensed to 
     offer such plan in each State and the benefits meet the 
     applicable requirements in each such State.
       (d) No Discrimination on the Basis of Provision of 
     Abortion.--No Exchange participating health benefits plan may 
     discriminate against any individual health care provider or 
     health care facility because of its willingness or 
     unwillingness to provide, pay for, provide coverage of, or 
     refer for abortions.

     SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE 
                   INDIVIDUALS AND EMPLOYERS IN EXCHANGE-
                   PARTICIPATING HEALTH BENEFITS PLAN.

       (a) In General.--
       (1) Outreach.--The Commissioner shall conduct outreach 
     activities consistent with subsection (c), including through 
     use of appropriate entities as described in paragraph (3) of 
     such subsection, to inform and educate individuals and 
     employers about the Health Insurance Exchange and Exchange-
     participating health benefits plan options. Such outreach 
     shall include outreach specific to vulnerable populations, 
     such as children, individuals with disabilities, individuals 
     with mental illness, and individuals with other cognitive 
     impairments.
       (2) Eligibility.--The Commissioner shall make timely 
     determinations of whether individuals and employers are 
     Exchange-eligible individuals and employers (as defined in 
     section 302).
       (3) Enrollment.--The Commissioner shall establish and carry 
     out an enrollment process for Exchange-eligible individuals 
     and employers, including at community locations, in 
     accordance with subsection (b).
       (b) Enrollment Process.--
       (1) In general.--The Commissioner shall establish a process 
     consistent with this title for enrollments in Exchange-
     participating health benefits plans. Such process shall 
     provide for enrollment through means such as the mail, by 
     telephone, electronically, and in person.
       (2) Enrollment periods.--
       (A) Open enrollment period.--The Commissioner shall 
     establish an annual open enrollment period during which an 
     Exchange-eligible individual or employer may elect to enroll 
     in an Exchange-participating health benefits plan for the 
     following plan year and an enrollment period for 
     affordability credits under subtitle C. Such periods shall be 
     during September through November of each year, or such other 
     time that would maximize timeliness of income verification 
     for purposes of such subtitle. The open enrollment period 
     shall not be less than 30 days.
       (B) Special enrollment.--The Commissioner shall also 
     provide for special enrollment periods to take into account 
     special circumstances of individuals and employers, such as 
     an individual who--
       (i) loses acceptable coverage;
       (ii) experiences a change in marital or other dependent 
     status;
       (iii) moves outside the service area of the Exchange-
     participating health benefits plan in which the individual is 
     enrolled; or
       (iv) experiences a significant change in income.
       (C) Enrollment information.--The Commissioner shall provide 
     for the broad dissemination of information to prospective 
     enrollees on the enrollment process, including before each 
     open enrollment period. In carrying out the previous 
     sentence, the Commissioner may work with other appropriate 
     entities to facilitate such provision of information.
       (3) Automatic enrollment for non-medicaid eligible 
     individuals.--
       (A) In general.--The Commissioner shall provide for a 
     process under which individuals who are Exchange-eligible 
     individuals described in subparagraph (B) are automatically 
     enrolled under an appropriate Exchange-participating health 
     benefits plan. Such process may involve a random assignment 
     or some other form of assignment that takes into account the 
     health care providers used by the individual involved or such 
     other relevant factors as the Commissioner may specify.
       (B) Subsidized individuals described.--An individual 
     described in this subparagraph is an Exchange-eligible 
     individual who is either of the following:

[[Page 27236]]

       (i) Affordability credit eligible individuals.--The 
     individual--

       (I) has applied for, and been determined eligible for, 
     affordability credits under subtitle C;
       (II) has not opted out from receiving such affordability 
     credit; and
       (III) does not otherwise enroll in another Exchange-
     participating health benefits plan.

       (ii) Individuals enrolled in a terminated plan.--The 
     individual who is enrolled in an Exchange-participating 
     health benefits plan that is terminated (during or at the end 
     of a plan year) and who does not otherwise enroll in another 
     Exchange-participating health benefits plan.
       (4) Direct payment of premiums to plans.--Under the 
     enrollment process, individuals enrolled in an Exchange-
     participating health benefits plan shall pay such plans 
     directly, and not through the Commissioner or the Health 
     Insurance Exchange.
       (c) Coverage Information and Assistance.--
       (1) Coverage information.--The Commissioner shall provide 
     for the broad dissemination of information on Exchange-
     participating health benefits plans offered under this title. 
     Such information shall be provided in a comparative manner, 
     and shall include information on benefits, premiums, cost-
     sharing, quality, provider networks, and consumer 
     satisfaction.
       (2) Consumer assistance with choice.--To provide assistance 
     to Exchange-eligible individuals and employers, the 
     Commissioner shall--
       (A) provide for the operation of a toll-free telephone 
     hotline to respond to requests for assistance and maintain an 
     Internet Web site through which individuals may obtain 
     information on coverage under Exchange-participating health 
     benefits plans and file complaints;
       (B) develop and disseminate information to Exchange-
     eligible enrollees on their rights and responsibilities;
       (C) assist Exchange-eligible individuals in selecting 
     Exchange-participating health benefits plans and obtaining 
     benefits through such plans; and
       (D) ensure that the Internet Web site described in 
     subparagraph (A) and the information described in 
     subparagraph (B) is developed using plain language (as 
     defined in section 233(a)(2)).
       (3) Use of other entities.--In carrying out this 
     subsection, the Commissioner may work with other appropriate 
     entities to facilitate the dissemination of information under 
     this subsection and to provide assistance as described in 
     paragraph (2).
       (d) Coverage for Certain Newborns Under Medicaid.--
       (1) In general.--In the case of a child born in the United 
     States who at the time of birth is not otherwise covered 
     under acceptable coverage, for the period of time beginning 
     on the date of birth and ending on the date the child 
     otherwise is covered under acceptable coverage (or, if 
     earlier, the end of the month in which the 60-day period, 
     beginning on the date of birth, ends), the child shall be 
     deemed--
       (A) to be a Medicaid eligible individual for purposes of 
     this division and Medicaid; and
       (B) to be automatically enrolled in Medicaid as a 
     traditional Medicaid eligible individual (as defined in 
     section 1943(c) of the Social Security Act).
       (2) Extended treatment as medicaid eligible individual.--In 
     the case of a child described in paragraph (1) who at the end 
     of the period referred to in such paragraph is not otherwise 
     covered under acceptable coverage, the child shall be deemed 
     (until such time as the child obtains such coverage or the 
     State otherwise makes a determination of the child's 
     eligibility for medical assistance under its Medicaid plan 
     pursuant to section 1943(b)(1) of the Social Security Act) to 
     be a Medicaid eligible individual described in section 
     1902(l)(1)(B) of such Act.
       (e) Medicaid Coverage for Medicaid Eligible Individuals.--
       (1) Medicaid enrollment obligation.--An individual may 
     apply, in the manner described in section 341(b)(1), for a 
     determination of whether the individual is a Medicaid-
     eligible individual. If the individual is determined to be so 
     eligible, the Commissioner, through the Medicaid memorandum 
     of understanding under paragraph (2), shall provide for the 
     enrollment of the individual under the State Medicaid plan in 
     accordance with such memorandum of understanding. In the case 
     of such an enrollment, the State shall provide for the same 
     periodic redetermination of eligibility under Medicaid as 
     would otherwise apply if the individual had directly applied 
     for medical assistance to the State Medicaid agency.
       (2) Coordinated enrollment with state through memorandum of 
     understanding.--The Commissioner, in consultation with the 
     Secretary of Health and Human Services, shall enter into a 
     memorandum of understanding with each State with respect to 
     coordinating enrollment of individuals in Exchange-
     participating health benefits plans and under the State's 
     Medicaid program consistent with this section and to 
     otherwise coordinate the implementation of the provisions of 
     this division with respect to the Medicaid program. Such 
     memorandum shall permit the exchange of information 
     consistent with the limitations described in section 
     1902(a)(7) of the Social Security Act. Nothing in this 
     section shall be construed as permitting such memorandum to 
     modify or vitiate any requirement of a State Medicaid plan.
       (f) Effective Culturally and Linguistically Appropriate 
     Communication.--In carrying out this section, the 
     Commissioner shall establish effective methods for 
     communicating in plain language and a culturally and 
     linguistically appropriate manner.
       (g) Role for Enrollment Agents and Brokers.--Nothing in 
     this division shall be construed to affect the role of 
     enrollment agents and brokers under State law, including with 
     regard to the enrollment of individuals and employers in 
     qualified health benefits plans including the public health 
     insurance option.
       (h) Assistance for Small Employers.--
       (1) In general.--The Commissioner, in consultation with the 
     Small Business Administration, shall establish and carry out 
     a program to provide to small employers counseling and 
     technical assistance with respect to the provision of health 
     insurance to employees of such employers through the Health 
     Insurance Exchange.
       (2) Duties.--The program established under paragraph (1) 
     shall include the following services:
       (A) Educational activities to increase awareness of the 
     Health Insurance Exchange and available small employer health 
     plan options.
       (B) Distribution of information to small employers with 
     respect to the enrollment and selection process for health 
     plans available under the Health Insurance Exchange, 
     including standardized comparative information on the health 
     plans available under the Health Insurance Exchange.
       (C) Distribution of information to small employers with 
     respect to available affordability credits or other financial 
     assistance.
       (D) Referrals to appropriate entities of complaints and 
     questions relating to the Health Insurance Exchange.
       (E) Enrollment and plan selection assistance for employers 
     with respect to the Health Insurance Exchange.
       (F) Responses to questions relating to the Health Insurance 
     Exchange and the program established under paragraph (1).
       (3) Authority to provide services directly or by 
     contract.--The Commissioner may provide services under 
     paragraph (2) directly or by contract with nonprofit entities 
     that the Commissioner determines capable of carrying out such 
     services.
       (4) Small employer defined.--In this subsection, the term 
     ``small employer'' means an employer with less than 100 
     employees.
       (i) Participation of Small Employer Benefit Arrangements.--
       (1) In general.--The Commissioner may enter into contracts 
     with small employer benefit arrangements to provide consumer 
     information, outreach, and assistance in the enrollment of 
     small employers (and their employees) who are members of such 
     an arrangement under Exchange participating health benefits 
     plans.
       (2) Small employer benefit arrangement defined.--In this 
     subsection, the term ``small employer benefit arrangement'' 
     means a not-for-profit agricultural or other cooperative 
     that--
       (A) consists solely of its members and is operated for the 
     primary purpose of providing affordable employee benefits to 
     its members;
       (B) only has as members small employers in the same 
     industry or line of business;
       (C) has no member that has more than a 5 percent voting 
     interest in the cooperative; and
       (D) is governed by a board of directors elected by its 
     members.

     SEC. 306. OTHER FUNCTIONS.

       (a) Coordination of Affordability Credits.--The 
     Commissioner shall coordinate the distribution of 
     affordability premium and cost-sharing credits under subtitle 
     C to QHBP offering entities offering Exchange-participating 
     health benefits plans.
       (b) Coordination of Risk Pooling.--The Commissioner shall 
     establish a mechanism whereby there is an adjustment made of 
     the premium amounts payable among QHBP offering entities 
     offering Exchange-participating health benefits plans of 
     premiums collected for such plans that takes into account (in 
     a manner specified by the Commissioner) the differences in 
     the risk characteristics of individuals and employees 
     enrolled under the different Exchange-participating health 
     benefits plans offered by such entities so as to minimize the 
     impact of adverse selection of enrollees among the plans 
     offered by such entities. For purposes of the previous 
     sentence, the Commissioner may utilize data regarding 
     enrollee demographics, inpatient and outpatient diagnoses (in 
     a similar manner as such data are used under parts C and D of 
     title XVIII of the Social Security Act), and such other 
     information as the Secretary determines may be necessary, 
     such as the actual medical costs of enrollees during the 
     previous year.

     SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND.

       (a) Establishment of Health Insurance Exchange Trust 
     Fund.--There is created within the Treasury of the United 
     States a trust fund to be known as the ``Health Insurance 
     Exchange Trust Fund'' (in this section

[[Page 27237]]

     referred to as the ``Trust Fund''), consisting of such 
     amounts as may be appropriated or credited to the Trust Fund 
     under this section or any other provision of law.
       (b) Payments From Trust Fund.--The Commissioner shall pay 
     from time to time from the Trust Fund such amounts as the 
     Commissioner determines are necessary to make payments to 
     operate the Health Insurance Exchange, including payments 
     under subtitle C (relating to affordability credits).
       (c) Transfers to Trust Fund.--
       (1) Dedicated payments.--There are hereby appropriated to 
     the Trust Fund amounts equivalent to the following:
       (A) Taxes on individuals not obtaining acceptable 
     coverage.--The amounts received in the Treasury under section 
     59B of the Internal Revenue Code of 1986 (relating to 
     requirement of health insurance coverage for individuals).
       (B) Employment taxes on employers not providing acceptable 
     coverage.--The amounts received in the Treasury under 
     sections 3111(c) and 3221(c) of the Internal Revenue Code of 
     1986 (relating to employers electing to not provide health 
     benefits).
       (C) Excise tax on failures to meet certain health coverage 
     requirements.--The amounts received in the Treasury under 
     section 4980H(b) (relating to excise tax with respect to 
     failure to meet health coverage participation requirements).
       (2) Appropriations to cover government contributions.--
     There are hereby appropriated, out of any moneys in the 
     Treasury not otherwise appropriated, to the Trust Fund, an 
     amount equivalent to the amount of payments made from the 
     Trust Fund under subsection (b) plus such amounts as are 
     necessary reduced by the amounts deposited under paragraph 
     (1).
       (d) Application of Certain Rules.--Rules similar to the 
     rules of subchapter B of chapter 98 of the Internal Revenue 
     Code of 1986 shall apply with respect to the Trust Fund.

     SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE 
                   EXCHANGES.

       (a) In General.--If--
       (1) a State (or group of States, subject to the approval of 
     the Commissioner) applies to the Commissioner for approval of 
     a State-based Health Insurance Exchange to operate in the 
     State (or group of States); and
       (2) the Commissioner approves such State-based Health 
     Insurance Exchange,
     then, subject to subsections (c) and (d), the State-based 
     Health Insurance Exchange shall operate, instead of the 
     Health Insurance Exchange, with respect to such State (or 
     group of States). The Commissioner shall approve a State-
     based Health Insurance Exchange if it meets the requirements 
     for approval under subsection (b).
       (b) Requirements for Approval.--
       (1) In general.--The Commissioner may not approve a State-
     based Health Insurance Exchange under this section unless the 
     following requirements are met:
       (A) The State-based Health Insurance Exchange must 
     demonstrate the capacity to and provide assurances 
     satisfactory to the Commissioner that the State-based Health 
     Insurance Exchange will carry out the functions specified for 
     the Health Insurance Exchange in the State (or States) 
     involved, including--
       (i) negotiating and contracting with QHBP offering entities 
     for the offering of Exchange-participating health benefits 
     plans, which satisfy the standards and requirements of this 
     title and title II;
       (ii) enrolling Exchange-eligible individuals and employers 
     in such State in such plans;
       (iii) the establishment of sufficient local offices to meet 
     the needs of Exchange-eligible individuals and employers;
       (iv) administering affordability credits under subtitle B 
     using the same methodologies (and at least the same income 
     verification methods) as would otherwise apply under such 
     subtitle and at a cost to the Federal Government which does 
     exceed the cost to the Federal Government if this section did 
     not apply; and
       (v) enforcement activities consistent with Federal 
     requirements.
       (B) There is no more than one Health Insurance Exchange 
     operating with respect to any one State.
       (C) The State provides assurances satisfactory to the 
     Commissioner that approval of such an Exchange will not 
     result in any net increase in expenditures to the Federal 
     Government.
       (D) The State provides for reporting of such information as 
     the Commissioner determines and assurances satisfactory to 
     the Commissioner that it will vigorously enforce violations 
     of applicable requirements.
       (E) Such other requirements as the Commissioner may 
     specify.
       (2) Presumption for certain state-operated exchanges.--
       (A) In general.--In the case of a State operating an 
     Exchange prior to January 1, 2010, that seeks to operate the 
     State-based Health Insurance Exchange under this section, the 
     Commissioner shall presume that such Exchange meets the 
     standards under this section unless the Commissioner 
     determines, after completion of the process established under 
     subparagraph (B), that the Exchange does not comply with such 
     standards.
       (B) Process.--The Commissioner shall establish a process to 
     work with a State described in subparagraph (A) to provide 
     assistance necessary to assure that the State's Exchange 
     comes into compliance with the standards for approval under 
     this section.
       (c) Ceasing Operation.--
       (1) In general.--A State-based Health Insurance Exchange 
     may, at the option of each State involved, and only after 
     providing timely and reasonable notice to the Commissioner, 
     cease operation as such an Exchange, in which case the Health 
     Insurance Exchange shall operate, instead of such State-based 
     Health Insurance Exchange, with respect to such State (or 
     States).
       (2) Termination; health insurance exchange resumption of 
     functions.--The Commissioner may terminate the approval (for 
     some or all functions) of a State-based Health Insurance 
     Exchange under this section if the Commissioner determines 
     that such Exchange no longer meets the requirements of 
     subsection (b) or is no longer capable of carrying out such 
     functions in accordance with the requirements of this 
     subtitle. In lieu of terminating such approval, the 
     Commissioner may temporarily assume some or all functions of 
     the State-based Health Insurance Exchange until such time as 
     the Commissioner determines the State-based Health Insurance 
     Exchange meets such requirements of subsection (b) and is 
     capable of carrying out such functions in accordance with the 
     requirements of this subtitle.
       (3) Effectiveness.--The ceasing or termination of a State-
     based Health Insurance Exchange under this subsection shall 
     be effective in such time and manner as the Commissioner 
     shall specify.
       (d) Retention of Authority.--
       (1) Authority retained.--Enforcement authorities of the 
     Commissioner shall be retained by the Commissioner.
       (2) Discretion to retain additional authority.--The 
     Commissioner may specify functions of the Health Insurance 
     Exchange that--
       (A) may not be performed by a State-based Health Insurance 
     Exchange under this section; or
       (B) may be performed by the Commissioner and by such a 
     State-based Health Insurance Exchange.
       (e) References.--In the case of a State-based Health 
     Insurance Exchange, except as the Commissioner may otherwise 
     specify under subsection (d), any references in this subtitle 
     to the Health Insurance Exchange or to the Commissioner in 
     the area in which the State-based Health Insurance Exchange 
     operates shall be deemed a reference to the State-based 
     Health Insurance Exchange and the head of such Exchange, 
     respectively.
       (f) Funding.--In the case of a State-based Health Insurance 
     Exchange, there shall be assistance provided for the 
     operation of such Exchange in the form of a matching grant 
     with a State share of expenditures required.

     SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS.

       (a) In General.--Effective January 1, 2015, 2 or more 
     States may form Health Care Choice Compacts (in this section 
     referred to as ``compacts'') to facilitate the purchase of 
     individual health insurance coverage across State lines.
       (b) Model Guidelines.--The Secretary of Health and Human 
     Services (in this section referred to as the ``Secretary'') 
     shall consult with the National Association of Insurance 
     Commissioners (in this section referred to as ``NAIC'') to 
     develop not later than January 1, 2014 model guidelines for 
     the creation of compacts. In developing such guidelines, the 
     Secretary shall consult with consumers, health insurance 
     issuers, and other interested parties. Such guidelines 
     shall--
       (1) provide for the sale of health insurance coverage to 
     residents of all compacting States subject to the laws and 
     regulations of a primary State designated by the compacting 
     States;
       (2) require health insurance issuers issuing health 
     insurance coverage in secondary States to maintain licensure 
     in every such State;
       (3) preserve the authority of the State of an individual's 
     residence to enforce law relating to--
       (A) market conduct;
       (B) unfair trade practices;
       (C) network adequacy;
       (D) consumer protection standards;
       (E) grievance and appeals;
       (F) fair claims payment requirements;
       (G) prompt payment of claims;
       (H) rate review; and
       (I) fraud;
       (4) permit State insurance commissioners and other State 
     agencies in secondary States access to the records of a 
     health insurance issuer to the same extent as if the policy 
     were written in that State; and
       (5) provide for clear and conspicuous disclosure to 
     consumers that the policy may not be subject to all the laws 
     and regulations of the State in which the purchaser resides.
       (c) No Requirement to Compact.--Nothing in this section 
     shall be construed to require a State to join a compact.
       (d) State Authority.--A State may not enter into a compact 
     under this subsection unless the State enacts a law after the 
     date of enactment of this Act that specifically authorizes 
     the State to enter into such compact.
       (e) Consumer Protections.--If a State enters into a compact 
     it must retain responsibility for the consumer protections of 
     its

[[Page 27238]]

     residents and its residents retain the right to bring a claim 
     in a State court in the State in which the resident resides.
       (f) Assistance to Compacting States.--
       (1) In general.--Beginning January 1, 2015, the Secretary 
     shall make awards, from amounts appropriated under paragraph 
     (5), to States in the amount specified in paragraph (2) for 
     the uses described in paragraph (3).
       (2) Amount specified.--
       (A) In general.--For each fiscal year, the Secretary shall 
     determine the total amount that the Secretary will make 
     available for grants under this subsection.
       (B) State amount.--For each State that is awarded a grant 
     under paragraph (1), the amount of such grants shall be based 
     on a formula established by the Secretary, not to exceed $1 
     million per State, under which States shall receive an award 
     in the amount that is based on the following two components:
       (i) A minimum amount for each State.
       (ii) An additional amount based on population of the State.
       (3) Use of funds.--A State shall use amounts awarded under 
     this subsection for activities (including planning 
     activities) related regulating health insurance coverage sold 
     in secondary States.
       (4) Renewability of grant.--The Secretary may renew a grant 
     award under paragraph (1) if the State receiving the grant 
     continues to be a member of a compact.
       (5) Authorization of appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this subsection in each of fiscal years 2015 through 2020.

     SEC. 310. HEALTH INSURANCE COOPERATIVES.

       (a) Establishment.--Not later than 6 months after the date 
     of the enactment of this Act, the Commissioner, in 
     consultation with the Secretary of the Treasury, shall 
     establish a Consumer Operated and Oriented Plan program (in 
     this section referred to as the ``CO-OP program'') under 
     which the Commissioner may make grants and loans for the 
     establishment and initial operation of not-for-profit, 
     member-run health insurance cooperatives (in this section 
     individually referred to as a ``cooperative'') that provide 
     insurance through the Health Insurance Exchange or a State-
     based Health Insurance Exchange under section 308. Nothing in 
     this section shall be construed as requiring a State to 
     establish such a cooperative.
       (b) Start-up and Solvency Grants and Loans.--
       (1) In general.--Not later than 36 months after the date of 
     the enactment of this Act, the Commissioner, acting through 
     the CO-OP program, may make--
       (A) loans (of such period and with such terms as the 
     Secretary may specify) to cooperatives to assist such 
     cooperatives with start-up costs; and
       (B) grants to cooperatives to assist such cooperatives in 
     meeting State solvency requirements in the States in which 
     such cooperative offers or issues insurance coverage.
       (2)  Conditions.--A grant or loan may not be awarded under 
     this subsection with respect to a cooperative unless the 
     following conditions are met:
       (A) The cooperative is structured as a not-for-profit, 
     member organization under the law of each State in which such 
     cooperative offers, intends to offer, or issues insurance 
     coverage, with the membership of the cooperative being made 
     up entirely of beneficiaries of the insurance coverage 
     offered by such cooperative.
       (B) The cooperative did not offer insurance on or before 
     July 16, 2009, and the cooperative is not an affiliate or 
     successor to an insurance company offering insurance on or 
     before such date.
       (C) The governing documents of the cooperative incorporate 
     ethical and conflict of interest standards designed to 
     protect against insurance industry involvement and 
     interference in the governance of the cooperative.
       (D) The cooperative is not sponsored by a State government.
       (E) Substantially all of the activities of the cooperative 
     consist of the issuance of qualified health benefits plans 
     through the Health Insurance Exchange or a State-based health 
     insurance exchange.
       (F) The cooperative is licensed to offer insurance in each 
     State in which it offers insurance.
       (G) The governance of the cooperative must be subject to a 
     majority vote of its members.
       (H) As provided in guidance issued by the Secretary of 
     Health and Human Services, the cooperative operates with a 
     strong consumer focus, including timeliness, responsiveness, 
     and accountability to members.
       (I) Any profits made by the cooperative are used to lower 
     premiums, improve benefits, or to otherwise improve the 
     quality of health care delivered to members.
       (3) Priority.--The Commissioner, in making grants and loans 
     under this subsection, shall give priority to cooperatives 
     that--
       (A) operate on a statewide basis;
       (B) use an integrated delivery system; or
       (C) have a significant level of financial support from 
     nongovernmental sources.
       (4) Rules of construction.--Nothing in this section shall 
     be construed to prevent a cooperative established in one 
     State from integrating with a cooperative established in 
     another State the administration, issuance of coverage, or 
     other activities related to acting as a QHBP offering entity. 
     Nothing in this section shall be construed as preventing 
     State governments from taking actions to permit such 
     integration.
       (5) Amortization of grants and loans.--The Secretary shall 
     provide for the repayment of grants or loans provided under 
     this subsection to the Treasury in an amortized manner over a 
     10-year period.
       (6) Repayment for violations of terms of program.--If a 
     cooperative violates the terms of the CO-OP program and fails 
     to correct the violation within a reasonable period of time, 
     as determined by the Commissioner, the cooperative shall 
     repay the total amount of any loan or grant received by such 
     cooperative under this section, plus interest (at a rate 
     determined by the Secretary).
       (7) Authorization of appropriations.--There is authorized 
     to be appropriated $5,000,000,000 for the period of fiscal 
     years 2010 through 2014 to provide for grants and loans under 
     this subsection.
       (c) Definitions.--For purposes of this section:
       (1) State.--The term ``State'' means each of the 50 States 
     and the District of Columbia.
       (2) Member.--The term ``member'', with respect to a 
     cooperative, means an individual who, after the cooperative 
     offers health insurance coverage, is enrolled in such 
     coverage.

     SEC. 311. RETENTION OF DOD AND VA AUTHORITY.

        Nothing in this subtitle shall be construed as affecting 
     any authority under title 38, United States Code, or chapter 
     55 of title 10, United States Code.

               Subtitle B--Public Health Insurance Option

     SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH 
                   INSURANCE OPTION AS AN EXCHANGE-QUALIFIED 
                   HEALTH BENEFITS PLAN.

       (a) Establishment.--For years beginning with Y1, the 
     Secretary of Health and Human Services (in this subtitle 
     referred to as the ``Secretary'') shall provide for the 
     offering of an Exchange-participating health benefits plan 
     (in this division referred to as the ``public health 
     insurance option'') that ensures choice, competition, and 
     stability of affordable, high quality coverage throughout the 
     United States in accordance with this subtitle. In designing 
     the option, the Secretary's primary responsibility is to 
     create a low-cost plan without compromising quality or access 
     to care.
       (b) Offering as an Exchange-participating Health Benefits 
     Plan.--
       (1) Exclusive to the exchange.--The public health insurance 
     option shall only be made available through the Health 
     Insurance Exchange.
       (2) Ensuring a level playing field.--Consistent with this 
     subtitle, the public health insurance option shall comply 
     with requirements that are applicable under this title to an 
     Exchange-participating health benefits plan, including 
     requirements related to benefits, benefit levels, provider 
     networks, notices, consumer protections, and cost-sharing.
       (3) Provision of benefit levels.--The public health 
     insurance option--A) shall offer basic, enhanced, and premium 
     plans; and
       (B) may offer premium-plus plans.
       (c) Administrative Contracting.--The Secretary may enter 
     into contracts for the purpose of performing administrative 
     functions (including functions described in subsection (a)(4) 
     of section 1874A of the Social Security Act) with respect to 
     the public health insurance option in the same manner as the 
     Secretary may enter into contracts under subsection (a)(1) of 
     such section. The Secretary has the same authority with 
     respect to the public health insurance option as the 
     Secretary has under subsections (a)(1) and (b) of section 
     1874A of the Social Security Act with respect to title XVIII 
     of such Act. Contracts under this subsection shall not 
     involve the transfer of insurance risk to such entity.
       (d) Ombudsman.--The Secretary shall establish an office of 
     the ombudsman for the public health insurance option which 
     shall have duties with respect to the public health insurance 
     option similar to the duties of the Medicare Beneficiary 
     Ombudsman under section 1808(c)(2) of the Social Security 
     Act.
       (e) Data Collection.--The Secretary shall collect such data 
     as may be required to establish premiums and payment rates 
     for the public health insurance option and for other purposes 
     under this subtitle, including to improve quality and to 
     reduce racial, ethnic, and other disparities in health and 
     health care. Nothing in this subtitle may be construed as 
     authorizing the Secretary (or any employee or contractor) to 
     create or maintain lists of non-medical personal property.
       (f) Treatment of Public Health Insurance Option.--With 
     respect to the public health insurance option, the Secretary 
     shall be treated as a QHBP offering entity offering an 
     Exchange-participating health benefits plan.
       (g) Access to Federal Courts.--The provisions of Medicare 
     (and related provisions of title II of the Social Security 
     Act) relating to access of Medicare beneficiaries to Federal 
     courts for the enforcement of rights

[[Page 27239]]

     under Medicare, including with respect to amounts in 
     controversy, shall apply to the public health insurance 
     option and individuals enrolled under such option under this 
     title in the same manner as such provisions apply to Medicare 
     and Medicare beneficiaries.

     SEC. 322. PREMIUMS AND FINANCING.

       (a) Establishment of Premiums.--
       (1) In general.--The Secretary shall establish 
     geographically adjusted premium rates for the public health 
     insurance option--
       (A) in a manner that complies with the premium rules 
     established by the Commissioner under section 213 for 
     Exchange-participating health benefits plans; and
       (B) at a level sufficient to fully finance the costs of--
       (i) health benefits provided by the public health insurance 
     option; and
       (ii) administrative costs related to operating the public 
     health insurance option.
       (2) Contingency margin.--In establishing premium rates 
     under paragraph (1), the Secretary shall include an 
     appropriate amount for a contingency margin (which shall be 
     not less than 90 days of estimated claims). Before setting 
     such appropriate amount for years starting with Y3, the 
     Secretary shall solicit a recommendation on such amount from 
     the American Academy of Actuaries.
       (b) Account.--
       (1) Establishment.--There is established in the Treasury of 
     the United States an Account for the receipts and 
     disbursements attributable to the operation of the public 
     health insurance option, including the start-up funding under 
     paragraph (2). Section 1854(g) of the Social Security Act 
     shall apply to receipts described in the previous sentence in 
     the same manner as such section applies to payments or 
     premiums described in such section.
       (2) Start-up funding.--
       (A) In general.--In order to provide for the establishment 
     of the public health insurance option, there is hereby 
     appropriated to the Secretary, out of any funds in the 
     Treasury not otherwise appropriated, $2,000,000,000. In order 
     to provide for initial claims reserves before the collection 
     of premiums, there are hereby appropriated to the Secretary, 
     out of any funds in the Treasury not otherwise appropriated, 
     such sums as necessary to cover 90 days worth of claims 
     reserves based on projected enrollment.
       (B) Amortization of start-up funding.--The Secretary shall 
     provide for the repayment of the startup funding provided 
     under subparagraph (A) to the Treasury in an amortized manner 
     over the 10-year period beginning with Y1.
       (C) Limitation on funding.--Nothing in this section shall 
     be construed as authorizing any additional appropriations to 
     the Account, other than such amounts as are otherwise 
     provided with respect to other Exchange-participating health 
     benefits plans.
       (3) No bailouts.--In no case shall the public health 
     insurance option receive any Federal funds for purposes of 
     insolvency in any manner similar to the manner in which 
     entities receive Federal funding under the Troubled Assets 
     Relief Program of the Secretary of the Treasury.

     SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.

       (a) Negotiation of Payment Rates.--
       (1) In general.--The Secretary shall negotiate payment for 
     the public health insurance option for health care providers 
     and items and services, including prescription drugs, 
     consistent with this section and section 324.
       (2) Manner of negotiation.--The Secretary shall negotiate 
     such rates in a manner that results in payment rates that are 
     not lower, in the aggregate, than rates under title XVIII of 
     the Social Security Act, and not higher, in the aggregate, 
     than the average rates paid by other QHBP offering entities 
     for services and health care providers.
       (3) Innovative payment methods.--Nothing in this subsection 
     shall be construed as preventing the use of innovative 
     payment methods such as those described in section 324 in 
     connection with the negotiation of payment rates under this 
     subsection.
       (4) Treatment of certain state waivers.--In the case of any 
     State operating a cost-containment waiver for health care 
     providers in accordance with section 1814(b)(3) of the Social 
     Security Act, the Secretary shall provide for payment to such 
     providers under the public health insurance option consistent 
     with the provisions and requirements of that waiver.
       (b) Establishment of a Provider Network.--
       (1) In general.--Health care providers (including 
     physicians and hospitals) participating in Medicare are 
     participating providers in the public health insurance option 
     unless they opt out in a process established by the Secretary 
     consistent with this subsection.
       (2) Requirements for opt-out process.--Under the process 
     established under paragraph (1)--
       (A) providers described in such paragraph shall be provided 
     at least a 1-year period prior to the first day of Y1 to opt 
     out of participating in the public health insurance option;
       (B) no provider shall be subject to a penalty for not 
     participating in the public health insurance option;
       (C) the Secretary shall include information on how 
     providers participating in Medicare who chose to opt out of 
     participating in the public health insurance option may opt 
     back in; and
       (D) there shall be an annual enrollment period in which 
     providers may decide whether to participate in the public 
     health insurance option.
       (3) Rulemaking.--Not later than 18 months before the first 
     day of Y1, the Secretary shall promulgate rules (pursuant to 
     notice and comment) for the process described in paragraph 
     (1).
       (c) Limitations on Review.--There shall be no 
     administrative or judicial review of a payment rate or 
     methodology established under this section or under section 
     324.

     SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM 
                   REFORM.

       (a) In General.--For plan years beginning with Y1, the 
     Secretary may utilize innovative payment mechanisms and 
     policies to determine payments for items and services under 
     the public health insurance option. The payment mechanisms 
     and policies under this section may include patient-centered 
     medical home and other care management payments, accountable 
     care organizations, value-based purchasing, bundling of 
     services, differential payment rates, performance or 
     utilization based payments, partial capitation, and direct 
     contracting with providers.
       (b) Requirements for Innovative Payments.--The Secretary 
     shall design and implement the payment mechanisms and 
     policies under this section in a manner that--
       (1) seeks to--
       (A) improve health outcomes;
       (B) reduce health disparities (including racial, ethnic, 
     and other disparities);
       (C) provide efficient and affordable care;
       (D) address geographic variation in the provision of health 
     services; or
       (E) prevent or manage chronic illness; and
       (2) promotes care that is integrated, patient-centered, 
     quality, and efficient.
       (c) Encouraging the Use of High Value Services.--To the 
     extent allowed by the benefit standards applied to all 
     Exchange-participating health benefits plans, the public 
     health insurance option may modify cost-sharing and payment 
     rates to encourage the use of services that promote health 
     and value.
       (d) Promotion of Delivery System Reform.--The Secretary 
     shall monitor and evaluate the progress of payment and 
     delivery system reforms under this Act and shall seek to 
     implement such reforms subject to the following:
       (1) To the extent that the Secretary finds a payment and 
     delivery system reform successful in improving quality and 
     reducing costs, the Secretary shall implement such reform on 
     as large a geographic scale as practical and economical.
       (2) The Secretary may delay the implementation of such a 
     reform in geographic areas in which such implementation would 
     place the public health insurance option at a competitive 
     disadvantage.
       (3) The Secretary may prioritize implementation of such a 
     reform in high cost geographic areas or otherwise in order to 
     reduce total program costs or to promote high value care.
       (e) Non-uniformity Permitted.--Nothing in this subtitle 
     shall prevent the Secretary from varying payments based on 
     different payment structure models (such as accountable care 
     organizations and medical homes) under the public health 
     insurance option for different geographic areas.

     SEC. 325. PROVIDER PARTICIPATION.

       (a) In General.--The Secretary shall establish conditions 
     of participation for health care providers under the public 
     health insurance option.
       (b) Licensure or Certification.--
       (1) In general.--Except as provided in paragraph (2), the 
     Secretary shall not allow a health care provider to 
     participate in the public health insurance option unless such 
     provider is appropriately licensed, certified, or otherwise 
     permitted to practice under State law.
       (2) Special rule for ihs facilities and providers.--The 
     requirements under paragraph (1) shall not apply to--
       (A) a facility that is operated by the Indian Health 
     Service;
       (B) a facility operated by an Indian Tribe or tribal 
     organization under the Indian Self-Determination Act (Public 
     Law 93-638);
       (C) a health care professional employed by the Indian 
     Health Service; or
       (D) a health care professional--
       (i) who is employed to provide health care services in a 
     facility operated by an Indian Tribe or tribal organization 
     under the Indian Self-Determination Act; and
       (ii) who is licensed or certified in any State.
       (c) Payment Terms for Providers.--
       (1) Physicians.--The Secretary shall provide for the annual 
     participation of physicians under the public health insurance 
     option, for which payment may be made for services furnished 
     during the year, in one of 2 classes:
       (A) Preferred physicians.--Those physicians who agree to 
     accept the payment under section 323 (without regard to cost-
     sharing) as the payment in full.

[[Page 27240]]

       (B) Participating, non-preferred physicians.--Those 
     physicians who agree not to impose charges (in relation to 
     the payment described in section 323 for such physicians) 
     that exceed the sum of the in-network cost-sharing plus 15 
     percent of the total payment for each item and service. The 
     Secretary shall reduce the payment described in section 323 
     for such physicians.
       (2) Other providers.--The Secretary shall provide for the 
     participation (on an annual or other basis specified by the 
     Secretary) of health care providers (other than physicians) 
     under the public health insurance option under which payment 
     shall only be available if the provider agrees to accept the 
     payment under section 323 (without regard to cost-sharing) as 
     the payment in full.
       (d) Exclusion of Certain Providers.--The Secretary shall 
     exclude from participation under the public health insurance 
     option a health care provider that is excluded from 
     participation in a Federal health care program (as defined in 
     section 1128B(f) of the Social Security Act).

     SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVISIONS.

       Provisions of civil law identified by the Secretary by 
     regulation, in consultation with the Inspector General of the 
     Department of Health and Human Services, that impose 
     sanctions with respect to waste, fraud, and abuse under 
     Medicare, such as sections 3729 through 3733 of title 31, 
     United States Code (commonly known as the False Claims Act), 
     shall also apply to the public health insurance option.

     SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIREMENTS.

       The requirements of sections 2701 through 2792 of the 
     Public Health Service Act shall apply to the public health 
     insurance option in the same manner as they apply to health 
     insurance coverage offered by a health insurance issuer in 
     the individual market.

     SEC. 328. APPLICATION OF HEALTH INFORMATION PRIVACY, 
                   SECURITY, AND ELECTRONIC TRANSACTION 
                   REQUIREMENTS.

       Part C of title XI of the Social Security Act, relating to 
     standards for protections against the wrongful disclosure of 
     individually identifiable health information, health 
     information security, and the electronic exchange of health 
     care information, shall apply to the public health insurance 
     option in the same manner as such part applies to other 
     health plans (as defined in section 1171(5) of such Act).

     SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION IS 
                   VOLUNTARY.

       Nothing in this division shall be construed as requiring 
     anyone to enroll in the public health insurance option. 
     Enrollment in such option is voluntary.

     SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION BY 
                   MEMBERS OF CONGRESS.

       Notwithstanding any other provision of this Act, Members of 
     Congress may enroll in the public health insurance option.

     SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS AFFAIRS.

       The Secretary of Health and Human Services shall seek to 
     enter into a memorandum of understanding with the Secretary 
     of Veterans Affairs regarding the recovery of costs related 
     to non-service-connected care or services provided by the 
     Secretary of Veterans Affairs to an individual covered under 
     the public health insurance option in a manner consistent 
     with recovery of costs related to non-service-connected care 
     from private health insurance plans.

              Subtitle C--Individual Affordability Credits

     SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.

       (a) In General.--Subject to the succeeding provisions of 
     this subtitle, in the case of an affordable credit eligible 
     individual enrolled in an Exchange-participating health 
     benefits plan--
       (1) the individual shall be eligible for, in accordance 
     with this subtitle, affordability credits consisting of--
       (A) an affordability premium credit under section 343 to be 
     applied against the premium for the Exchange-participating 
     health benefits plan in which the individual is enrolled; and
       (B) an affordability cost-sharing credit under section 344 
     to be applied as a reduction of the cost-sharing otherwise 
     applicable to such plan; and
       (2) the Commissioner shall pay the QHBP offering entity 
     that offers such plan from the Health Insurance Exchange 
     Trust Fund the aggregate amount of affordability credits for 
     all affordable credit eligible individuals enrolled in such 
     plan.
       (b) Application.--
       (1) In general.--An Exchange eligible individual may apply 
     to the Commissioner through the Health Insurance Exchange or 
     through another entity under an arrangement made with the 
     Commissioner, in a form and manner specified by the 
     Commissioner. The Commissioner through the Health Insurance 
     Exchange or through another public entity under an 
     arrangement made with the Commissioner shall make a 
     determination as to eligibility of an individual for 
     affordability credits under this subtitle. The Commissioner 
     shall establish a process whereby, on the basis of 
     information otherwise available, individuals may be deemed to 
     be affordable credit eligible individuals. In carrying this 
     subtitle, the Commissioner shall establish effective methods 
     that ensure that individuals with limited English proficiency 
     are able to apply for affordability credits.
       (2) Use of state medicaid agencies.--If the Commissioner 
     determines that a State Medicaid agency has the capacity to 
     make a determination of eligibility for affordability credits 
     under this subtitle and under the same standards as used by 
     the Commissioner, under the Medicaid memorandum of 
     understanding under section 305(e)(2)--
       (A) the State Medicaid agency is authorized to conduct such 
     determinations for any Exchange-eligible individual who 
     requests such a determination; and
       (B) the Commissioner shall reimburse the State Medicaid 
     agency for the costs of conducting such determinations.
       (3) Medicaid screen and enroll obligation.--In the case of 
     an application made under paragraph (1), there shall be a 
     determination of whether the individual is a Medicaid-
     eligible individual. If the individual is determined to be so 
     eligible, the Commissioner, through the Medicaid memorandum 
     of understanding under section 305(e)(2), shall provide for 
     the enrollment of the individual under the State Medicaid 
     plan in accordance with such Medicaid memorandum of 
     understanding. In the case of such an enrollment, the State 
     shall provide for the same periodic redetermination of 
     eligibility under Medicaid as would otherwise apply if the 
     individual had directly applied for medical assistance to the 
     State Medicaid agency.
       (4) Application and verification of requirement of 
     citizenship or lawful presence in the united states.--
       (A) Requirement.--No individual shall be an affordable 
     credit eligible individual (as defined in section 342(a)(1)) 
     unless the individual is a citizen or national of the United 
     States or is lawfully present in a State in the United States 
     (other than as a nonimmigrant described in a subparagraph 
     (excluding subparagraphs (K), (T), (U), and (V)) of section 
     101(a)(15) of the Immigration and Nationality Act).
       (B) Declaration of citizenship or lawful immigration 
     status.--No individual shall be an affordable credit eligible 
     individual unless there has been a declaration made, in a 
     form and manner specified by the Health Choices Commissioner 
     similar to the manner required under section 1137(d)(1) of 
     the Social Security Act and under penalty of perjury, that 
     the individual--
       (i) is a citizen or national of the United States; or
       (ii) is not such a citizen or national but is lawfully 
     present in a State in the United States (other than as a 
     nonimmigrant described in a subparagraph (excluding 
     subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) 
     of the Immigration and Nationality Act).

     Such declaration shall be verified in accordance with 
     subparagraph (C) or (D), as the case may be.
       (C) Verification process for citizens.--
       (i) In general.--In the case of an individual making the 
     declaration described in subparagraph (B)(i), subject to 
     clause (ii), section 1902(ee) of the Social Security Act 
     shall apply to such declaration in the same manner as such 
     section applies to a declaration described in paragraph (1) 
     of such section.
       (ii) Special rules.--In applying section 1902(ee) of such 
     Act under clause (i)--

       (I) any reference in such section to a State is deemed a 
     reference to the Commissioner (or other public entity making 
     the eligibility determination);
       (II) any reference to medical assistance or enrollment 
     under a State plan is deemed a reference to provision of 
     affordability credits under this subtitle;
       (III) a reference to a newly enrolled individual under 
     paragraph (2)(A) of such section is deemed a reference to an 
     individual newly in receipt of an affordability credit under 
     this subtitle;
       (IV) approval by the Secretary shall not be required in 
     applying paragraph (2)(B)(ii) of such section;
       (V) paragraph (3) of such section shall not apply; and
       (VI) before the end of Y2, the Health Choices Commissioner, 
     in consultation with the Commissioner of Social Security, may 
     extend the periods specified in paragraph (1)(B)(ii) of such 
     section.

       (D) Verification process for noncitizens.--
       (i) In general.--In the case of an individual making the 
     declaration described in subparagraph (B)(ii), subject to 
     clause (ii), the verification procedures of paragraphs (2) 
     through (5) of section 1137(d) of the Social Security Act 
     shall apply to such declaration in the same manner as such 
     procedures apply to a declaration described in paragraph (1) 
     of such section.
       (ii) Special rules.--In applying such paragraphs of section 
     1137(d) of such Act under clause (i)--

       (I) any reference in such paragraphs to a State is deemed a 
     reference to the Health Choices Commissioner; and
       (II) any reference to benefits under a program is deemed a 
     reference to affordability credits under this subtitle.

[[Page 27241]]

       (iii) Application to state-based exchanges.--In the case of 
     the application of the verification process under this 
     subparagraph to a State-based Health Insurance Exchange 
     approved under section 308, section 1137(e) of such Act shall 
     apply to the Health Choices Commissioner in relation to the 
     State.
       (E) Annual reports.--The Health Choices Commissioner shall 
     report to Congress annually on the number of applicants for 
     affordability credits under this subtitle, their citizenship 
     or immigration status, and the disposition of their 
     applications. Such report shall be made publicly available 
     and shall include information on--
       (i) the number of applicants whose declaration of 
     citizenship or immigration status, name, or social security 
     account number was not consistent with records maintained by 
     the Commissioner of Social Security or the Department of 
     Homeland Security and, of such applicants, the number who 
     contested the inconsistency and sought to document their 
     citizenship or immigration status, name, or social security 
     account number or to correct the information maintained in 
     such records and, of those, the results of such 
     contestations; and
       (ii) the administrative costs of conducting the status 
     verification under this paragraph.
       (F) GAO report.--Not later than the end of Y2, the 
     Comptroller General of the United States shall submit to the 
     Committee on Ways and Means, the Committee on Energy and 
     Commerce, the Committee on Education and Labor, and the 
     Committee on the Judiciary of the House of Representatives 
     and the Committee on Finance, the Committee on Health, 
     Education, Labor, and Pensions, and the Committee on the 
     Judiciary of the Senate a report examining the effectiveness 
     of the citizenship and immigration verification systems 
     applied under this paragraph. Such report shall include an 
     analysis of the following:
       (i) The causes of erroneous determinations under such 
     systems.
       (ii) The effectiveness of the processes used in remedying 
     such erroneous determinations.
       (iii) The impact of such systems on individuals, health 
     care providers, and Federal and State agencies, including the 
     effect of erroneous determinations under such systems.
       (iv) The effectiveness of such systems in preventing 
     ineligible individuals from receiving for affordability 
     credits.
       (v) The characteristics of applicants described in 
     subparagraph (E)(i).
       (G) Prohibition of database.--Nothing in this paragraph or 
     the amendments made by paragraph (6) shall be construed as 
     authorizing the Health Choices Commissioner or the 
     Commissioner of Social Security to establish a database of 
     information on citizenship or immigration status.
       (H) Initial funding.--
       (i) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to the 
     Commissioner of Social Security $30,000,000, to be available 
     without fiscal year limit to carry out this paragraph and 
     section 205(v) of the Social Security Act.
       (ii) Funding limitation.--In no case shall funds from the 
     Social Security Administration's Limitation on Administrative 
     Expenses be used to carry out activities related to this 
     paragraph or section 205(v) of the Social Security Act.
       (5) Agreement with social security commissioner.--
       (A) In general.--The Health Choices Commissioner shall 
     enter into and maintain an agreement described in section 
     205(v)(2) of the Social Security Act with the Commissioner of 
     Social Security.
       (B) Funding.--The agreement entered into under subparagraph 
     (A) shall, for each fiscal year (beginning with fiscal year 
     2013)--
       (i) provide funds to the Commissioner of Social Security 
     for the full costs of the responsibilities of the 
     Commissioner of Social Security under paragraph (4), 
     including--

       (I) acquiring, installing, and maintaining technological 
     equipment and systems necessary for the fulfillment of the 
     responsibilities of the Commissioner of Social Security under 
     paragraph (4), but only that portion of such costs that are 
     attributable to such responsibilities; and
       (II) responding to individuals who contest with the 
     Commissioner of Social Security a reported inconsistency with 
     records maintained by the Commissioner of Social Security or 
     the Department of Homeland Security relating to citizenship 
     or immigration status, name, or social security account 
     number under paragraph (4);

       (ii) based on an estimating methodology agreed to by the 
     Commissioner of Social Security and the Health Choices 
     Commissioner, provide such funds, within 10 calendar days of 
     the beginning of the fiscal year for the first quarter and in 
     advance for all subsequent quarters in that fiscal year; and
       (iii) provide for an annual accounting and reconciliation 
     of the actual costs incurred and the funds provided under the 
     agreement.
       (C) Review of accounting.--The annual accounting and 
     reconciliation conducted pursuant to subparagraph (B)(iii) 
     shall be reviewed by the Inspectors General of the Social 
     Security Administration and the Health Choices 
     Administration, including an analysis of consistency with the 
     requirements of paragraph (4).
       (D) Contingency.--In any case in which agreement with 
     respect to the provisions required under subparagraph (B) for 
     any fiscal year has not been reached as of the first day of 
     such fiscal year, the latest agreement with respect to such 
     provisions shall be deemed in effect on an interim basis for 
     such fiscal year until such time as an agreement relating to 
     such provisions is subsequently reached. In any case in which 
     an interim agreement applies for any fiscal year under this 
     subparagraph, the Commissioner of Social Security shall, not 
     later than the first day of such fiscal year, notify the 
     appropriate Committees of the Congress of the failure to 
     reach the agreement with respect to such provisions for such 
     fiscal year. Until such time as the agreement with respect to 
     such provisions has been reached for such fiscal year, the 
     Commissioner of Social Security shall, not later than the end 
     of each 90-day period after October 1 of such fiscal year, 
     notify such Committees of the status of negotiations between 
     such Commissioner and the Health Choices Commissioner in 
     order to reach such an agreement.
       (E) Application to public entities administering 
     affordability credits.--If the Health Choices Commissioner 
     provides for the conduct of verifications under paragraph (4) 
     through a public entity, the Health Choices Commissioner 
     shall require the public entity to enter into an agreement 
     with the Commissioner of Social Security which provides the 
     same terms as the agreement described in this paragraph (and 
     section 205(v) of the Social Security Act) between the Health 
     Choices Commissioner and the Commissioner of Social Security, 
     except that the Health Choices Commissioner shall be 
     responsible for providing funds for the Commissioner of 
     Social Security in accordance with subparagraphs (B) through 
     (D).
       (6) Amendments to social security act.--
       (A) Coordination of information between social security 
     administration and health choices administration.--
       (i) In general.--Section 205 of the Social Security Act (42 
     U.S.C. 405) is amended by adding at the end the following new 
     subsection:

    ``Coordination of Information With Health Choices Administration

       ``(v)(1) The Health Choices Commissioner may collect and 
     use the names and social security account numbers of 
     individuals as required to provide for verification of 
     citizenship under subsection (b)(4)(C) of section 341 of the 
     Affordable Health Care for America Act in connection with 
     determinations of eligibility for affordability credits under 
     such section.
       ``(2)(A) The Commissioner of Social Security shall enter 
     into and maintain an agreement with the Health Choices 
     Commissioner for the purpose of establishing, in compliance 
     with the requirements of section 1902(ee) as applied pursuant 
     to section 341(b)(4)(C) of the Affordable Health Care for 
     America Act, a program for verifying information required to 
     be collected by the Health Choices Commissioner under such 
     section 341(b)(4)(C).
       ``(B) The agreement entered into pursuant to subparagraph 
     (A) shall include such safeguards as are necessary to ensure 
     the maintenance of confidentiality of any information 
     disclosed for purposes of verifying information described in 
     subparagraph (A) and to provide procedures for permitting the 
     Health Choices Commissioner to use the information for 
     purposes of maintaining the records of the Health Choices 
     Administration.
       ``(C) The agreement entered into pursuant to subparagraph 
     (A) shall provide that information provided by the 
     Commissioner of Social Security to the Health Choices 
     Commissioner pursuant to the agreement shall be provided at 
     such time, at such place, and in such manner as the 
     Commissioner of Social Security determines appropriate.
       ``(D) Information provided by the Commissioner of Social 
     Security to the Health Choices Commissioner pursuant to an 
     agreement entered into pursuant to subparagraph (A) shall be 
     considered as strictly confidential and shall be used only 
     for the purposes described in this paragraph and for carrying 
     out such agreement. Any officer or employee or former officer 
     or employee of the Health Choices Commissioner, or any 
     officer or employee or former officer or employee of a 
     contractor of the Health Choices Commissioner, who, without 
     the written authority of the Commissioner of Social Security, 
     publishes or communicates any information in such 
     individual's possession by reason of such employment or 
     position as such an officer shall be guilty of a felony and, 
     upon conviction thereof, shall be fined or imprisoned, or 
     both, as described in section 208.
       ``(3) The agreement entered into under paragraph (2) shall 
     provide for funding to the Commissioner of Social Security 
     consistent with section 341(b)(5) of Affordable Health Care 
     for America Act.
       ``(4) This subsection shall apply in the case of a public 
     entity that conducts verifications under section 341(b)(4) of 
     the Affordable Health Care for America Act and the 
     obligations of this subsection shall apply to such an entity 
     in the same manner as such obligations apply to the Health 
     Choices Commissioner when such Commissioner is conducting 
     such verifications.''.

[[Page 27242]]

       (ii) Conforming amendment.--Section 205(c)(2)(C) of such 
     Act (42 U.S.C. 405(c)(2)(C)) is amended by adding at the end 
     the following new clause:
       ``(x) For purposes of the administration of the 
     verification procedures described in section 341(b)(4) of the 
     Affordable Health Care for America Act, the Health Choices 
     Commissioner may collect and use social security account 
     numbers as provided for in section 205(v)(1).''.
       (B) Improving the integrity of data and effectiveness of 
     save program.--Section 1137(d) of the Social Security Act (42 
     U.S.C. 1320b-7(d)) is amended by adding at the end the 
     following new paragraphs:
       ``(6)(A) With respect to the use by any agency of the 
     system described in subsection (b) by programs specified in 
     subsection (b) or any other use of such system, the U.S. 
     Citizenship and Immigration Services and any other agency 
     charged with the management of the system shall establish 
     appropriate safeguards necessary to protect and improve the 
     integrity and accuracy of data relating to individuals by--
       ``(i) establishing a process through which such individuals 
     are provided access to, and the ability to amend, correct, 
     and update, their own personally identifiable information 
     contained within the system;
       ``(ii) providing a written response, without undue delay, 
     to any individual who has made such a request to amend, 
     correct, or update such individual's own personally 
     identifiable information contained within the system; and
       ``(iii) developing a written notice for user agencies to 
     provide to individuals who are denied a benefit due to a 
     determination of ineligibility based on a final verification 
     determination under the system.
       ``(B) The notice described in subparagraph (A)(ii) shall 
     include--
       ``(i) information about the reason for such notice;
       ``(ii) a description of the right of the recipient of the 
     notice under subparagraph (A)(i) to contest such notice;
       ``(iii) a description of the right of the recipient under 
     subparagraph (A)(i) to access and attempt to amend, correct, 
     and update the recipient's own personally identifiable 
     information contained within records of the system described 
     in paragraph (3); and
       ``(iv) instructions on how to contest such notice and 
     attempt to correct records of such system relating to the 
     recipient, including contact information for relevant 
     agencies.''.
       (C) Streamlining administration of verification process for 
     united states citizens.--Section 1902(ee)(2) of the Social 
     Security Act (42 U.S.C. 1396a(ee)(2)) is amended by adding at 
     the end the following:
       ``(D) In carrying out the verification procedures under 
     this subsection with respect to a State, if the Commissioner 
     of Social Security determines that the records maintained by 
     such Commissioner are not consistent with an individual's 
     allegation of United States citizenship, pursuant to 
     procedures which shall be established by the State in 
     coordination with the Commissioner of Social Security, the 
     Secretary of Homeland Security, and the Secretary of Health 
     and Human Services--
       ``(i) the Commissioner of Social Security shall inform the 
     State of the inconsistency;
       ``(ii) upon being so informed of the inconsistency, the 
     State shall submit the information on the individual to the 
     Secretary of Homeland Security for a determination of whether 
     the records of the Department of Homeland Security indicate 
     that the individual is a citizen;
       ``(iii) upon making such determination, the Department of 
     Homeland Security shall inform the State of such 
     determination; and
       ``(iv) information provided by the Commissioner of Social 
     Security shall be considered as strictly confidential and 
     shall only be used by the State and the Secretary of Homeland 
     Security for the purposes of such verification procedures.
       ``(E) Verification of status eligibility pursuant to the 
     procedures established under this subsection shall be deemed 
     a verification of status eligibility for purposes of this 
     title, title XXI, and affordability credits under section 
     341(b)(4) of the Affordable Health Care for America Act, 
     regardless of the program in which the individual is applying 
     for benefits.''.
       (c) Use of Affordability Credits.--
       (1) In general.--In Y1 and Y2 an affordable credit eligible 
     individual may use an affordability credit only with respect 
     to a basic plan.
       (2) Flexibility in plan enrollment authorized.--Beginning 
     with Y3, the Commissioner shall establish a process to allow 
     an affordability premium credit under section 343, but not 
     the affordability cost-sharing credit under section 344, to 
     be used for enrollees in enhanced or premium plans. In the 
     case of an affordable credit eligible individual who enrolls 
     in an enhanced or premium plan, the individual shall be 
     responsible for any difference between the premium for such 
     plan and the affordability credit amount otherwise applicable 
     if the individual had enrolled in a basic plan.
       (3) Prohibition of use of public funds for abortion 
     coverage.--An affordability credit may not be used for 
     payment for services described in section 222(e)(4)(A).
       (d) Access to Data.--In carrying out this subtitle, the 
     Commissioner shall request from the Secretary of the Treasury 
     consistent with section 6103 of the Internal Revenue Code of 
     1986 such information as may be required to carry out this 
     subtitle.
       (e) No Cash Rebates.--In no case shall an affordable credit 
     eligible individual receive any cash payment as a result of 
     the application of this subtitle.

     SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

       (a) Definition.--
       (1) In general.--For purposes of this division, the term 
     ``affordable credit eligible individual'' means, subject to 
     subsection (b) and section 346, an individual who is lawfully 
     present in a State in the United States (other than as a 
     nonimmigrant described in a subparagraph (excluding 
     subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) 
     of the Immigration and Nationality Act)--
       (A) who is enrolled under an Exchange-participating health 
     benefits plan and is not enrolled under such plan as an 
     employee (or dependent of an employee) through an employer 
     qualified health benefits plan that meets the requirements of 
     section 412;
       (B) with modified adjusted gross income below 400 percent 
     of the Federal poverty level for a family of the size 
     involved;
       (C) who is not a Medicaid eligible individual, other than 
     an individual during a transition period under section 
     302(d)(3)(B)(ii); and
       (D) subject to paragraph (3), who is not enrolled in 
     acceptable coverage (other than an Exchange-participating 
     health benefits plan).
       (2) Treatment of family.--Except as the Commissioner may 
     otherwise provide, members of the same family who are 
     affordable credit eligible individuals shall be treated as a 
     single affordable credit individual eligible for the 
     applicable credit for such a family under this subtitle.
       (3) Special rule for indians.--Subparagraph (D) of 
     paragraph (1) shall not apply to an individual who has 
     coverage that is treated as acceptable coverage for purposes 
     of section 59B(d)(2) of the Internal Revenue Code of 1986 but 
     is not treated as acceptable coverage for purposes of this 
     division.
       (b) Limitations on Employee and Dependent 
     Disqualification.--
       (1) In general.--Subject to paragraph (2), the term 
     ``affordable credit eligible individual'' does not include a 
     full-time employee of an employer if the employer offers the 
     employee coverage (for the employee and dependents) as a 
     full-time employee under a group health plan if the coverage 
     and employer contribution under the plan meet the 
     requirements of section 412.
       (2) Exceptions.--
       (A) For certain family circumstances.--The Commissioner 
     shall establish such exceptions and special rules in the case 
     described in paragraph (1) as may be appropriate in the case 
     of a divorced or separated individual or such a dependent of 
     an employee who would otherwise be an affordable credit 
     eligible individual.
       (B) For unaffordable employer coverage.--Beginning in Y2, 
     in the case of full-time employees for which the cost of the 
     employee premium for coverage under a group health plan would 
     exceed 12 percent of current modified adjusted gross income 
     (determined by the Commissioner on the basis of verifiable 
     documentation), paragraph (1) shall not apply.
       (c) Income Defined.--
       (1) In general.--In this title, the term ``income'' means 
     modified adjusted gross income (as defined in section 59B of 
     the Internal Revenue Code of 1986).
       (2) Study of income disregards.--The Commissioner shall 
     conduct a study that examines the application of income 
     disregards for purposes of this subtitle. Not later than the 
     first day of Y2, the Commissioner shall submit to Congress a 
     report on such study and shall include such recommendations 
     as the Commissioner determines appropriate.
       (d) Clarification of Treatment of Affordability Credits.--
     Affordability credits under this subtitle shall not be 
     treated, for purposes of title IV of the Personal 
     Responsibility and Work Opportunity Reconciliation Act of 
     1996, to be a benefit provided under section 403 of such 
     title.

     SEC. 343. AFFORDABILITY PREMIUM CREDIT.

       (a) In General.--The affordability premium credit under 
     this section for an affordable credit eligible individual 
     enrolled in an Exchange-participating health benefits plan is 
     in an amount equal to the amount (if any) by which the 
     reference premium amount specified in subsection (c), exceeds 
     the affordable premium amount specified in subsection (b) for 
     the individual, except that in no case shall the affordable 
     premium credit exceed the premium for the plan.
       (b) Affordable Premium Amount.--
       (1) In general.--The affordable premium amount specified in 
     this subsection for an individual for the annual premium in a 
     plan year shall be equal to the product of--
       (A) the premium percentage limit specified in paragraph (2) 
     for the individual based upon the individual's modified 
     adjusted gross income for the plan year; and
       (B) the individual's modified adjusted gross income for 
     such plan year.
       (2) Premium percentage limits based on table.--The 
     Commissioner shall establish

[[Page 27243]]

     premium percentage limits so that for individuals whose 
     modified adjusted gross income is within an income tier 
     specified in the table in subsection (d) such percentage 
     limits shall increase, on a sliding scale in a linear manner, 
     from the initial premium percentage to the final premium 
     percentage specified in such table for such income tier.
       (c) Reference Premium Amount.--The reference premium amount 
     specified in this subsection for a plan year for an 
     individual in a premium rating area is equal to the average 
     premium for the 3 basic plans in the area for the plan year 
     with the lowest premium levels. In computing such amount the 
     Commissioner may exclude plans with extremely limited 
     enrollments.
       (d) Table of Premium Percentage Limits, Actuarial Value 
     Percentages, and Out-of-pocket Limits for Y1 Based on Income 
     Tier.--
       (1) In general.--For purposes of this subtitle, subject to 
     paragraph (3) and section 346, the table specified in this 
     subsection is as follows:

 
   In the case of modified
    adjusted gross income
 (expressed as a percent of   The initial premium   The final premium   The actuarial value   The out-of-pocket
  FPL) within the following     percentage is--      percentage is--      percentage is--     limit for Y1 is--
        income tier:
 
133% through 150%             1.5%                 3.0%                 97%                  $500
150% through 200%             3.0%                 5.5%                 93%                  $1,000
200% through 250%             5.5%                 8.0%                 85%                  $2,000
250% through 300%             8.0%                 10.0%                78%                  $4,000
300% through 350%             10.0%                11.0%                72%                  $4,500
350% through 400%             11.0%                12.0%                70%                  $5,000
 


       (2) Special rules.--For purposes of applying the table 
     under paragraph (1):
       (A) For lowest level of income.--In the case of an 
     individual with income that does not exceed 133 percent of 
     FPL, the individual shall be considered to have income that 
     is 133 percent of FPL.
       (B) Application of higher actuarial value percentage at 
     tier transition points.--If two actuarial value percentages 
     may be determined with respect to an individual, the 
     actuarial value percentage shall be the higher of such 
     percentages.
       (3) Indexing.--For years after Y1, the Commissioner shall 
     adjust the initial and final premium percentages to maintain 
     the ratio of governmental to enrollee shares of premiums over 
     time, for each income tier identified in the table in 
     paragraph (1).

     SEC. 344. AFFORDABILITY COST-SHARING CREDIT.

       (a) In General.--The affordability cost-sharing credit 
     under this section for an affordable credit eligible 
     individual enrolled in an Exchange-participating health 
     benefits plan is in the form of the cost-sharing reduction 
     described in subsection (b) provided under this section for 
     the income tier in which the individual is classified based 
     on the individual's modified adjusted gross income.
       (b) Cost-sharing Reductions.--The Commissioner shall 
     specify a reduction in cost-sharing amounts and the annual 
     limitation on cost-sharing specified in section 222(c)(2)(B) 
     under a basic plan for each income tier specified in the 
     table under section 343(d), with respect to a year, in a 
     manner so that, as estimated by the Commissioner--
       (1) the actuarial value of the coverage with such reduced 
     cost-sharing amounts (and the reduced annual cost-sharing 
     limit) is equal to the actuarial value percentage (specified 
     in the table under section 343(d) for the income tier 
     involved) of the full actuarial value if there were no cost-
     sharing imposed under the plan; and
       (2) the annual limitation on cost-sharing specified in 
     section 222(c)(2)(B) is reduced to a level that does not 
     exceed the maximum out-of-pocket limit specified in 
     subsection (c).
       (c) Maximum Out-of-pocket Limit.--
       (1) In general.--Subject to paragraph (2), the maximum out-
     of-pocket limit specified in this subsection for an 
     individual within an income tier--
       (A) for individual coverage--
       (i) for Y1 is the out-of-pocket limit for Y1 specified in 
     subsection (c) in the table under section 343(d) for the 
     income tier involved; or
       (ii) for a subsequent year is such out-of-pocket limit for 
     the previous year under this subparagraph increased (rounded 
     to the nearest $10) for each subsequent year by the 
     percentage increase in the enrollment-weighted average of 
     premium increases for basic plans applicable to such year; or
       (B) for family coverage is twice the maximum out-of-pocket 
     limit under subparagraph (A) for the year involved.
       (2) Adjustment.--The Commissioner shall adjust the maximum 
     out-of-pocket limits under paragraph (1) to ensure that such 
     limits meet the actuarial value percentage specified in the 
     table under section 343(d) for the income tier involved.
       (d) Determination and Payment of Cost-sharing Affordability 
     Credit.--In the case of an affordable credit eligible 
     individual in a tier enrolled in an Exchange-participating 
     health benefits plan offered by a QHBP offering entity, the 
     Commissioner shall provide for payment to the offering entity 
     of an amount equivalent to the increased actuarial value of 
     the benefits under the plan provided under section 
     303(c)(2)(B) resulting from the reduction in cost-sharing 
     described in subsections (b) and (c).

     SEC. 345. INCOME DETERMINATIONS.

       (a) In General.--In applying this subtitle for an 
     affordability credit for an individual for a plan year, the 
     individual's income shall be the income (as defined in 
     section 342(c)) for the individual for the most recent 
     taxable year (as determined in accordance with rules of the 
     Commissioner). The Federal poverty level applied shall be 
     such level in effect as of the date of the application.
       (b) Program Integrity; Income Verification Procedures.--
       (1) Program integrity.--The Commissioner shall take such 
     steps as may be appropriate to ensure the accuracy of 
     determinations and redeterminations under this subtitle.
       (2) Income verification.--
       (A) In general.--Upon an initial application of an 
     individual for an affordability credit under this subtitle 
     (or in applying section 342(b)) or upon an application for a 
     change in the affordability credit based upon a significant 
     change in modified adjusted gross income described in 
     subsection (c)(1)--
       (i) the Commissioner shall request from the Secretary of 
     the Treasury the disclosure to the Commissioner of such 
     information as may be permitted to verify the information 
     contained in such application; and
       (ii) the Commissioner shall use the information so 
     disclosed to verify such information.
       (B) Alternative procedures.--The Commissioner shall 
     establish procedures for the verification of income for 
     purposes of this subtitle if no income tax return is 
     available for the most recent completed tax year.
       (c) Special Rules.--
       (1) Changes in income as a percent of fpl.--In the case 
     that an individual's income (expressed as a percentage of the 
     Federal poverty level for a family of the size involved) for 
     a plan year is expected (in a manner specified by the 
     Commissioner) to be significantly different from the income 
     (as so expressed) used under subsection (a), the Commissioner 
     shall establish rules requiring an individual to report, 
     consistent with the mechanism established under paragraph 
     (2), significant changes in such income (including a 
     significant change in family composition) to the Commissioner 
     and requiring the substitution of such income for the income 
     otherwise applicable.
       (2) Reporting of significant changes in income.--The 
     Commissioner shall establish rules under which an individual 
     determined to be an affordable credit eligible individual 
     would be required to inform the Commissioner when there is a 
     significant change in the modified adjusted gross income of 
     the individual (expressed as a percentage of the FPL for a 
     family of the size involved) and of the information regarding 
     such change. Such mechanism shall provide for guidelines that 
     specify the circumstances that qualify as a significant 
     change, the verifiable information required to document such 
     a change, and the process for submission of such information. 
     If the Commissioner receives new information from an 
     individual regarding the modified adjusted gross income of 
     the individual, the Commissioner shall provide for a 
     redetermination of the individual's eligibility to be an 
     affordable credit eligible individual.
       (3) Transition for chip.--In the case of a child described 
     in section 302(d)(4), the Commissioner shall establish rules 
     under which the modified adjusted gross income of the child 
     is deemed to be no greater than the family income of the 
     child as most recently determined before Y1 by the State 
     under title XXI of the Social Security Act.
       (4) Study of geographic variation in application of fpl.--
       (A) In general.--The Secretary of Health and Human Services 
     shall conduct a study to examine the feasibility and 
     implication of adjusting the application of the Federal 
     poverty level under this subtitle for different geographic 
     areas so as to reflect the variations in cost-of-living among 
     different areas within the United States. If the Secretary 
     determines that an adjustment is feasible, the study should 
     include a methodology to make such an adjustment. Not later 
     than the first day of Y1, the Secretary shall submit to 
     Congress a report on such study and shall include such 
     recommendations as the Secretary determines appropriate.
       (B) Inclusion of territories.--
       (i) In general.--The Secretary shall ensure that the study 
     under subparagraph (A) covers the territories of the United 
     States and that special attention is paid to the disparity 
     that exists among poverty levels and

[[Page 27244]]

     the cost of living in such territories and to the impact of 
     such disparity on efforts to expand health coverage and 
     ensure health care.
       (ii) Territories defined.--In this subparagraph, the term 
     ``territories of the United States'' includes the 
     Commonwealth of Puerto Rico, the United States Virgin 
     Islands, Guam, the Northern Mariana Islands, and any other 
     territory or possession of the United States.
       (d) Penalties for Misrepresentation.--In the case of an 
     individual who intentionally misrepresents modified adjusted 
     gross income or the individual fails (without regard to 
     intent) to disclose to the Commissioner a significant change 
     in modified adjusted gross income under subsection (c) in a 
     manner that results in the individual becoming an affordable 
     credit eligible individual when the individual is not or in 
     the amount of the affordability credit exceeding the correct 
     amount--
       (1) the individual is liable for repayment of the amount of 
     the improper affordability credit; and
       (2) in the case of such an intentional misrepresentation or 
     other egregious circumstances specified by the Commissioner, 
     the Commissioner may impose an additional penalty.

     SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRITORIES.

       (a) One-time Election for Treatment and Application of 
     Funding.--
       (1) In general.--A territory may elect, in a form and 
     manner specified by the Commissioner in consultation with the 
     Secretary of Health and Human Services and the Secretary of 
     the Treasury and not later than October 1, 2012, either--
       (A) to be treated as a State for purposes of applying this 
     title and title II; or
       (B) not to be so treated but instead, to have the dollar 
     limitation otherwise applicable to the territory under 
     subsections (f) and (g) of section 1108 of the Social 
     Security Act (42 U.S.C. 1308) for a fiscal year increased by 
     a dollar amount equivalent to the cap amount determined under 
     subsection (c)(2) for the territory as applied by the 
     Secretary for the fiscal year involved.
       (2) Conditions for acceptance.--The Commissioner has the 
     nonreviewable authority to accept or reject an election 
     described in paragraph (1)(A). Any such acceptance is--
       (A) contingent upon entering into an agreement described in 
     subsection (b) between the Commissioner and the territory and 
     subsection (c); and
       (B) subject to the approval of the Secretary of Health and 
     Human Services and the Secretary of the Treasury and subject 
     to such other terms and conditions as the Commissioner, in 
     consultation with such Secretaries, may specify.
       (3) Default rule.--A territory failing to make such an 
     election (or having an election under paragraph (1)(A) not 
     accepted under paragraph (2)) shall be treated as having made 
     the election described in paragraph (1)(B).
       (b) Agreement for Substitution of Percentages for 
     Affordability Credits.--
       (1) Negotiation.--In the case of a territory making an 
     election under subsection (a)(1)(A) (in this section referred 
     to as an ``electing territory'') , the Commissioner, in 
     consultation with the Secretaries of Health and Human 
     Services and the Treasury, shall enter into negotiations with 
     the government of such territory so that, before Y1, there is 
     an agreement reached between the parties on the percentages 
     that shall be applied under paragraph (2) for that territory. 
     The Commissioner shall not enter into such an agreement 
     unless--
       (A) payments made under this subtitle with respect to 
     residents of the territory are consistent with the cap 
     established under subsection (c) for such territory and with 
     subsection (d); and
       (B) the requirements of paragraphs (3) and (4) are met.
       (2) Application of substitute percentages and dollar 
     amounts.--In the case of an electing territory, there shall 
     be substituted in section 342(a)(1)(B) and in the table in 
     section 341(d)(1) for 400 percent, 133 percent, and other 
     percentages and dollar amounts specified in such table, such 
     respective percentages and dollar amounts as are established 
     under the agreement under paragraph (1) consistent with the 
     following:
       (A) No income gap between medicaid and affordability 
     credits.--The substituted percentages shall be specified in a 
     manner so as to prevent any gap in coverage for individuals 
     between income level at which medical assistance is available 
     through Medicaid and the income level at which affordability 
     credits are available.
       (B) Adjustment for out-of-pocket responsibility for 
     premiums and cost-sharing in relation to income.--The 
     substituted percentages of FPL for income tiers under such 
     table shall be specified in a manner so that--
       (i) affordable credit eligible individuals residing in the 
     territory bear the same out-of-pocket responsibility for 
     premiums and cost-sharing in relation to average income for 
     residents in that territory, as
       (ii) the out-of-pocket responsibility for premiums and 
     cost-sharing for affordable credit eligible individuals 
     residing in the 50 States or the District of Columbia in 
     relation to average income for such residents.
       (3) Special rules with respect to application of tax and 
     penalty provisions.--The electing territory shall enact one 
     or more laws under which provisions similar to the following 
     provisions apply with respect to such territory:
       (A) Section 59B of the Internal Revenue Code of 1986, 
     except that any resident of the territory who is not an 
     affordable credit eligible individual but who would be an 
     affordable credit eligible individual if such resident were a 
     resident of one of the 50 States (and any qualifying child 
     residing with such individual) may be treated as covered by 
     acceptable coverage.
       (B) Section 4980H of the Internal Revenue Code of 1986 and 
     section 502(c)(11) of the Employee Retirement Income Security 
     Act of 1974.
       (C) Section 3121(c) of the Internal Revenue Code of 1986.
       (4) Implementation of insurance reform and consumer 
     protection requirements.--The electing territory shall enact 
     and implement such laws and regulations as may be required to 
     apply the requirements of title II with respect to health 
     insurance coverage offered in the territory.
       (c) Cap on Additional Expenditures.--
       (1) In general.--In entering into an agreement with an 
     electing territory under subsection (b), the Commissioner 
     shall ensure that the aggregate expenditures under this 
     subtitle with respect to residents of such territory during 
     the period beginning with Y1 and ending with 2019 will not 
     exceed the cap amount specified in paragraph (2) for such 
     territory. The Commissioner shall adjust from time to time 
     the percentages applicable under such agreement as needed in 
     order to carry out the previous sentence.
       (2) Cap amount.--
       (A) In general.--The cap amount specified in this 
     paragraph--
       (i) for Puerto Rico is $3,700,000,000 increased by the 
     amount (if any) elected under subparagraph (C); or
       (ii) for another territory is the portion of $300,000,000 
     negotiated for such territory under subparagraph (B).
       (B) Negotiation for certain territories.--The Commissioner 
     in consultation with the Secretary of Health and Human 
     Services shall negotiate with the governments of the 
     territories (other than Puerto Rico) to allocate the amount 
     specified in subparagraph (A)(ii) among such territories.
       (C) Optional supplementation for puerto rico.--
       (i) In general.--Puerto Rico may elect, in a form and 
     manner specified by the Secretary of Health and Human 
     Services in consultation with the Commissioner to increase 
     the dollar amount specified in subparagraph (A)(i) by up to 
     $1,000,000,000.
       (ii) Offset in medicaid cap.--If Puerto Rico makes the 
     election described in clause (i), the Secretary shall 
     decrease the dollar limitation otherwise applicable to Puerto 
     Rico under subsections (f) and (g) of section 1108 of the 
     Social Security Act (42 U.S.C. 1308) for a fiscal year by the 
     additional aggregate payments the Secretary estimates will be 
     payable under this section for the fiscal year because of 
     such election.
       (d) Limitation on Funding.--In no case shall this section 
     (including the agreement under subsection (b)) permit--
       (1) the obligation of funds for expenditures under this 
     subtitle for periods beginning on or after January 1, 2020; 
     or
       (2) any increase in the dollar limitation described in 
     subsection (a)(1)(B) for any portion of any fiscal year 
     occurring on or after such date.

     SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

       Nothing in this subtitle shall allow Federal payments for 
     affordability credits on behalf of individuals who are not 
     lawfully present in the United States.

                    TITLE IV--SHARED RESPONSIBILITY

                 Subtitle A--Individual Responsibility

     SEC. 401. INDIVIDUAL RESPONSIBILITY.

       For an individual's responsibility to obtain acceptable 
     coverage, see section 59B of the Internal Revenue Code of 
     1986 (as added by section 501 of this Act).

                  Subtitle B--Employer Responsibility

           PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

     SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

       An employer meets the requirements of this section if such 
     employer does all of the following:
       (1) Offer of coverage.--The employer offers each employee 
     individual and family coverage under a qualified health 
     benefits plan (or under a current employment-based health 
     plan (within the meaning of section 202(b))) in accordance 
     with section 412.
       (2) Contribution towards coverage.--If an employee accepts 
     such offer of coverage, the employer makes timely 
     contributions towards such coverage in accordance with 
     section 412.
       (3) Contribution in lieu of coverage.--Beginning with Y2, 
     if an employee declines such offer but otherwise obtains 
     coverage in an Exchange-participating health benefits plan 
     (other than by reason of being covered by family coverage as 
     a spouse or dependent of the primary insured), the employer 
     shall

[[Page 27245]]

     make a timely contribution to the Health Insurance Exchange 
     with respect to each such employee in accordance with section 
     413.

     SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARD 
                   EMPLOYEE AND DEPENDENT COVERAGE.

       (a) In General.--An employer meets the requirements of this 
     section with respect to an employee if the following 
     requirements are met:
       (1) Offering of coverage.--The employer offers the coverage 
     described in section 411(1). In the case of an Exchange-
     eligible employer, the employer may offer such coverage 
     either through an Exchange-participating health benefits plan 
     or other than through such a plan.
       (2) Employer required contribution.--The employer timely 
     pays to the issuer of such coverage an amount not less than 
     the employer required contribution specified in subsection 
     (b) for such coverage.
       (3) Provision of information.--The employer provides the 
     Health Choices Commissioner, the Secretary of Labor, the 
     Secretary of Health and Human Services, and the Secretary of 
     the Treasury, as applicable, with such information as the 
     Commissioner may require to ascertain compliance with the 
     requirements of this section, including the following:
       (A) The name, date, and employer identification number of 
     the employer.
       (B) A certification as to whether the employer offers to 
     its full-time employees (and their dependents) the 
     opportunity to enroll in a qualified health benefits plan or 
     a current employment-based health plan (within the meaning of 
     section 202(b)).
       (C) If the employer certifies that the employer did offer 
     to its full-time employees (and their dependents) the 
     opportunity to so enroll--
       (i) the months during the calendar year for which such 
     coverage was available; and
       (ii) the monthly premium for the lowest cost option in each 
     of the enrollment categories under each such plan offered to 
     employees.
       (D) The name, address, and TIN of each full-time employee 
     during the calendar year and the months (if any) during which 
     such employee (and any dependents) were covered under any 
     such plans.
       (4) Autoenrollment of employees.--The employer provides for 
     autoenrollment of the employee in accordance with subsection 
     (c).
     This subsection shall supersede any law of a State which 
     would prevent automatic payroll deduction of employee 
     contributions to an employment-based health plan.
       (b) Reduction of Employee Premiums Through Minimum Employer 
     Contribution.--
       (1) Full-time employees.--The minimum employer contribution 
     described in this subsection for coverage of a full-time 
     employee (and, if any, the employee's spouse and qualifying 
     children (as defined in section 152(c) of the Internal 
     Revenue Code of 1986)) under a qualified health benefits plan 
     (or current employment-based health plan) is equal to--
       (A) in case of individual coverage, not less than 72.5 
     percent of the applicable premium (as defined in section 
     4980B(f)(4) of such Code, subject to paragraph (2)) of the 
     lowest cost plan offered by the employer that is a qualified 
     health benefits plan (or is such current employment-based 
     health plan); and
       (B) in the case of family coverage which includes coverage 
     of such spouse and children, not less 65 percent of such 
     applicable premium of such lowest cost plan.
       (2) Applicable premium for exchange coverage.--In this 
     subtitle, the amount of the applicable premium of the lowest 
     cost plan with respect to coverage of an employee under an 
     Exchange-participating health benefits plan is the reference 
     premium amount under section 343(c) for individual coverage 
     (or, if elected, family coverage) for the premium rating area 
     in which the individual or family resides.
       (3) Minimum employer contribution for employees other than 
     full-time employees.--In the case of coverage for an employee 
     who is not a full-time employee, the amount of the minimum 
     employer contribution under this subsection shall be a 
     proportion (as determined in accordance with rules of the 
     Health Choices Commissioner, the Secretary of Labor, the 
     Secretary of Health and Human Services, and the Secretary of 
     the Treasury, as applicable) of the minimum employer 
     contribution under this subsection with respect to a full-
     time employee that reflects the proportion of--
       (A) the average weekly hours of employment of the employee 
     by the employer, to
       (B) the minimum weekly hours specified by the Commissioner 
     for an employee to be a full-time employee.
       (4) Salary reductions not treated as employer 
     contributions.--For purposes of this section, any 
     contribution on behalf of an employee with respect to which 
     there is a corresponding reduction in the compensation of the 
     employee shall not be treated as an amount paid by the 
     employer.
       (c) Automatic Enrollment for Employer Sponsored Health 
     Benefits.--
       (1) In general.--The requirement of this subsection with 
     respect to an employer and an employee is that the employer 
     automatically enroll such employee into the employment-based 
     health benefits plan for individual coverage under the plan 
     option with the lowest applicable employee premium.
       (2) Opt-out.--In no case may an employer automatically 
     enroll an employee in a plan under paragraph (1) if such 
     employee makes an affirmative election to opt out of such 
     plan or to elect coverage under an employment-based health 
     benefits plan offered by such employer. An employer shall 
     provide an employee with a 30-day period to make such an 
     affirmative election before the employer may automatically 
     enroll the employee in such a plan.
       (3) Notice requirements.--
       (A) In general.--Each employer described in paragraph (1) 
     who automatically enrolls an employee into a plan as 
     described in such paragraph shall provide the employees, 
     within a reasonable period before the beginning of each plan 
     year (or, in the case of new employees, within a reasonable 
     period before the end of the enrollment period for such a new 
     employee), written notice of the employees' rights and 
     obligations relating to the automatic enrollment requirement 
     under such paragraph. Such notice must be comprehensive and 
     understood by the average employee to whom the automatic 
     enrollment requirement applies.
       (B) Inclusion of specific information.--The written notice 
     under subparagraph (A) must explain an employee's right to 
     opt out of being automatically enrolled in a plan and in the 
     case that more than one level of benefits or employee premium 
     level is offered by the employer involved, the notice must 
     explain which level of benefits and employee premium level 
     the employee will be automatically enrolled in the absence of 
     an affirmative election by the employee.

     SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

       (a) In General.--A contribution is made in accordance with 
     this section with respect to an employee if such contribution 
     is equal to an amount equal to 8 percent of the average wages 
     paid by the employer during the period of enrollment 
     (determined by taking into account all employees of the 
     employer and in such manner as the Commissioner provides, 
     including rules providing for the appropriate aggregation of 
     related employers) but not to exceed the minimum employer 
     contribution described in section 412(b)(1)(A). Any such 
     contribution--
       (1) shall be paid to the Health Choices Commissioner for 
     deposit into the Health Insurance Exchange Trust Fund; and
       (2) shall not be applied against the premium of the 
     employee under the Exchange-participating health benefits 
     plan in which the employee is enrolled.
       (b) Special Rules for Small Employers.--
       (1) In general.--In the case of any employer who is a small 
     employer for any calendar year, subsection (a) shall be 
     applied by substituting the applicable percentage determined 
     in accordance with the following table for ``8 percent'':


If the annual payroll of such employer   The applicable percentage is:
 for the preceding calendar year:
  Does not exceed $500,000.............  0 percent
  Exceeds $500,000, but does not exceed  2 percent
   $585,000.
  Exceeds $585,000, but does not exceed  4 percent
   $670,000.
  Exceeds $670,000, but does not exceed  6 percent
   $750,000.
 


       (2) Small employer.--For purposes of this subsection, the 
     term ``small employer'' means any employer for any calendar 
     year if the annual payroll of such employer for the preceding 
     calendar year does not exceed $750,000.
       (3) Annual payroll.--For purposes of this paragraph, the 
     term ``annual payroll'' means, with respect to any employer 
     for any calendar year, the aggregate wages paid by the 
     employer during such calendar year.
       (4) Aggregation rules.--Related employers and predecessors 
     shall be treated as a single employer for purposes of this 
     subsection.

     SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING.

       The Health Choices Commissioner (in coordination with the 
     Secretary of Labor, the Secretary of Health and Human 
     Services, and the Secretary of the Treasury) shall have 
     authority to set standards for determining whether employers 
     or insurers are undertaking any actions to affect the risk 
     pool within the Health Insurance Exchange by inducing 
     individuals to decline coverage under a qualified health 
     benefits plan (or current employment-based health plan 
     (within the meaning of section 202(b)) offered by the 
     employer and instead to enroll in an

[[Page 27246]]

     Exchange-participating health benefits plan. An employer 
     violating such standards shall be treated as not meeting the 
     requirements of this section.

     SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY 
                   REQUIREMENTS.

       (a) In General.--The Secretary of Labor shall conduct a 
     study to examine the effect of the exemptions under section 
     512(a) and coverage thresholds under this division (in this 
     section referred to collectively as ``employer responsibility 
     requirements'' on employment-based health plan sponsorship, 
     generally and within specific industries, and the effect of 
     such requirements and thresholds on employers, employment-
     based health plans, and employees in each industry.
       (b) Annual Report.--The Secretary of Labor annually shall 
     submit to Congress a report on findings on how employer 
     responsibility requirements have impacted and are likely to 
     impact employers, plans, and employees during the previous 
     year and projected trends.
       (c) Legislative Recommendations.--No later than January 1, 
     2012 and on an annual basis thereafter, the Secretary of 
     Labor shall submit legislative recommendations to Congress to 
     modify the employer responsibility requirements if the 
     Secretary determines that the requirements are detrimentally 
     affecting or will detrimentally affect employer plan 
     sponsorship or otherwise creating inequities among employers, 
     health plans, and employees. The Secretary may also submit 
     such recommendations as the Secretary determines necessary to 
     improve and strengthen employment-based health plan 
     sponsorship, employer responsibility, and related proposals 
     that would enhance the delivery of health care benefits 
     between employers and employees.

     SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION.

       (a) In General.--The Secretary of Labor together with the 
     Secretary of Treasury, the Secretary of Health and Human 
     Services, and the Commissioner, shall conduct a study to 
     examine the impact of the employer responsibility 
     requirements described in section 415(a) and make a 
     recommendation to Congress about whether an employer hardship 
     exemption would be appropriate.
       (b) Items Included in Study.--Within such study the 
     Secretaries and Commissioner shall examine cases where such 
     employer responsibility requirements may pose a particular 
     hardship, and specifically look at employers by industry, 
     profit margin, length of time in business, and size. In this 
     examination, the economic conditions shall be considered, 
     including the rate of increase in business costs, the 
     availability of short-term credit lines, and abilities to 
     restructure debt. In addition, the study shall examine the 
     impact an employer hardship waiver could have on employees.
       (c) Report.--Not later than January 1, 2012, the 
     Secretaries and Commissioner shall report to Congress on 
     their findings and make a recommendation regarding the need 
     or lack of need for a partial or complete employer hardship 
     waiver. The Secretaries and Commissioner may also submit 
     recommendations about the criteria Congress should include 
     when developing eligibility requirements for the employer 
     hardship waiver and what safeguards are necessary to protect 
     the employees of that employer.

   PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

     SEC. 421. SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
                   REQUIREMENTS UNDER THE EMPLOYEE RETIREMENT 
                   INCOME SECURITY ACT OF 1974.

       (a) In General.--Subtitle B of title I of the Employee 
     Retirement Income Security Act of 1974 is amended by adding 
     at the end the following new part:

     ``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

     ``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL 
                   HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

       ``(a) In General.--An employer may make an election with 
     the Secretary to be subject to the health coverage 
     participation requirements.
       ``(b) Time and Manner.--An election under subsection (a) 
     may be made at such time and in such form and manner as the 
     Secretary may prescribe.

     ``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

       ``(a) In General.--If an employer makes an election to the 
     Secretary under section 801--
       ``(1) such election shall be treated as the establishment 
     and maintenance of a group health plan (as defined in section 
     733(a)) for purposes of this title, subject to section 251 of 
     the Affordable Health Care for America Act; and
       ``(2) the health coverage participation requirements shall 
     be deemed to be included as terms and conditions of such 
     plan.
       ``(b) Periodic Investigations To Discover Noncompliance.--
     The Secretary shall regularly audit a representative sampling 
     of employers and group health plans and conduct 
     investigations and other activities under section 504 with 
     respect to such sampling of plans so as to discover 
     noncompliance with the health coverage participation 
     requirements in connection with such plans. The Secretary 
     shall communicate findings of noncompliance made by the 
     Secretary under this subsection to the Secretary of the 
     Treasury and the Health Choices Commissioner. The Secretary 
     shall take such timely enforcement action as appropriate to 
     achieve compliance.
       ``(c) Recordkeeping.--To facilitate the audits described in 
     subsection (b), the Secretary shall promulgate recordkeeping 
     requirements for employers to account for both employees of 
     the employer and individuals whom the employer has not 
     treated as employees of the employer but with whom the 
     employer, in the course of its trade or business, has engaged 
     for the performance of labor or services. The scope and 
     content of such recordkeeping requirements shall be 
     determined by the Secretary and shall be designed to ensure 
     that employees who are not properly treated as such may be 
     identified and properly treated.

     ``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

       ``For purposes of this part, the term `health coverage 
     participation requirements' means the requirements of part 1 
     of subtitle B of title IV of division A of (as in effect on 
     the date of the enactment of such Act).

     ``SEC. 804. RULES FOR APPLYING REQUIREMENTS.

       ``(a) Affiliated Groups.--In the case of any employer which 
     is part of a group of employers who are treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414 of the Internal Revenue Code of 1986, the election under 
     section 801 shall be made by such employer as the Secretary 
     may provide. Any such election, once made, shall apply to all 
     members of such group.
       ``(b) Separate Elections.--Under regulations prescribed by 
     the Secretary, separate elections may be made under section 
     801 with respect to--
       ``(1) separate lines of business, and
       ``(2) full-time employees and employees who are not full-
     time employees.

     ``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL 
                   NONCOMPLIANCE.

       ``The Secretary may terminate the election of any employer 
     under section 801 if the Secretary (in coordination with the 
     Health Choices Commissioner) determines that such employer is 
     in substantial noncompliance with the health coverage 
     participation requirements and shall refer any such 
     determination to the Secretary of the Treasury as 
     appropriate.

     ``SEC. 806. REGULATIONS.

       ``The Secretary may promulgate such regulations as may be 
     necessary or appropriate to carry out the provisions of this 
     part, in accordance with section 424(a) of the . The 
     Secretary may promulgate any interim final rules as the 
     Secretary determines are appropriate to carry out this 
     part.''.
       (b) Enforcement of Health Coverage Participation 
     Requirements.--Section 502 of such Act (29 U.S.C. 1132) is 
     amended--
       (1) in subsection (a)(6), by striking ``paragraph'' and all 
     that follows through ``subsection (c)'' and inserting 
     ``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) 
     of subsection (c)''; and
       (2) in subsection (c), by redesignating the second 
     paragraph (10) as paragraph (12) and by inserting after the 
     first paragraph (10) the following new paragraph:
       ``(11) Health coverage participation requirements.--
       ``(A) Civil penalties.--In the case of any employer who 
     fails (during any period with respect to which an election 
     under section 801(a) is in effect) to satisfy the health 
     coverage participation requirements with respect to any 
     employee, the Secretary may assess a civil penalty against 
     the employer of $100 for each day in the period beginning on 
     the date such failure first occurs and ending on the date 
     such failure is corrected.
       ``(B) Health coverage participation requirements.--For 
     purposes of this paragraph, the term `health coverage 
     participation requirements' has the meaning provided in 
     section 803.
       ``(C) Limitations on amount of penalty.--
       ``(i) Penalty not to apply where failure not discovered 
     exercising reasonable diligence.--No penalty shall be 
     assessed under subparagraph (A) with respect to any failure 
     during any period for which it is established to the 
     satisfaction of the Secretary that the employer did not know, 
     or exercising reasonable diligence would not have known, that 
     such failure existed.
       ``(ii) Penalty not to apply to failures corrected within 30 
     days.--No penalty shall be assessed under subparagraph (A) 
     with respect to any failure if--

       ``(I) such failure was due to reasonable cause and not to 
     willful neglect, and
       ``(II) such failure is corrected during the 30-day period 
     beginning on the 1st date that the employer knew, or 
     exercising reasonable diligence would have known, that such 
     failure existed.

       ``(iii) Overall limitation for unintentional failures.--In 
     the case of failures which are due to reasonable cause and 
     not to willful neglect, the penalty assessed under 
     subparagraph (A) for failures during any 1-

[[Page 27247]]

     year period shall not exceed the amount equal to the lesser 
     of--

       ``(I) 10 percent of the aggregate amount paid or incurred 
     by the employer (or predecessor employer) during the 
     preceding 1-year period for group health plans, or
       ``(II) $500,000.

       ``(D) Advance notification of failure prior to 
     assessment.--Before a reasonable time prior to the assessment 
     of any penalty under this paragraph with respect to any 
     failure by an employer, the Secretary shall inform the 
     employer in writing of such failure and shall provide the 
     employer information regarding efforts and procedures which 
     may be undertaken by the employer to correct such failure.
       ``(E) Coordination with excise tax.--Under regulations 
     prescribed in accordance with section 424 of the Affordable 
     Health Care for America Act, the Secretary and the Secretary 
     of the Treasury shall coordinate the assessment of penalties 
     under this section in connection with failures to satisfy 
     health coverage participation requirements with the 
     imposition of excise taxes on such failures under section 
     4980H(b) of the Internal Revenue Code of 1986 so as to avoid 
     duplication of penalties with respect to such failures.
       ``(F) Deposit of penalty collected.--Any amount of penalty 
     collected under this paragraph shall be deposited as 
     miscellaneous receipts in the Treasury of the United 
     States.''.
       (c) Clerical Amendments.--The table of contents in section 
     1 of such Act is amended by inserting after the item relating 
     to section 734 the following new items:

     ``Part 8--National Health Coverage Participation Requirements

``Sec. 801. Election of employer to be subject to national health 
              coverage participation requirements.
``Sec. 802. Treatment of coverage resulting from election.
``Sec. 803. Health coverage participation requirements.
``Sec. 804. Rules for applying requirements.
``Sec. 805. Termination of election in cases of substantial 
              noncompliance.
``Sec. 806. Regulations.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to periods beginning after December 31, 2012.

     SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
                   REQUIREMENTS UNDER THE INTERNAL REVENUE CODE OF 
                   1986.

       (a) Failure To Elect, or Substantially Comply With, Health 
     Coverage Participation Requirements.--For employment tax on 
     employers who fail to elect, or substantially comply with, 
     the health coverage participation requirements described in 
     part 1, see section 3111(c) of the Internal Revenue Code of 
     1986 (as added by section 512 of this Act).
       (b) Other Failures.--For excise tax on other failures of 
     electing employers to comply with such requirements, see 
     section 4980H of the Internal Revenue Code of 1986 (as added 
     by section 511 of this Act).

     SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICIPATION 
                   REQUIREMENTS UNDER THE PUBLIC HEALTH SERVICE 
                   ACT.

       (a) In General.--Part C of title XXVII of the Public Health 
     Service Act is amended by adding at the end the following new 
     section:

     ``SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION 
                   REQUIREMENTS.

       ``(a) Election of Employer To Be Subject to National Health 
     Coverage Participation Requirements.--
       ``(1) In general.--An employer may make an election with 
     the Secretary to be subject to the health coverage 
     participation requirements.
       ``(2) Time and manner.--An election under paragraph (1) may 
     be made at such time and in such form and manner as the 
     Secretary may prescribe.
       ``(b) Treatment of Coverage Resulting From Election.--
       ``(1) In general.--If an employer makes an election to the 
     Secretary under subsection (a)--
       ``(A) such election shall be treated as the establishment 
     and maintenance of a group health plan for purposes of this 
     title, subject to section 251 of the Affordable Health Care 
     for America Act; and
       ``(B) the health coverage participation requirements shall 
     be deemed to be included as terms and conditions of such 
     plan.
       ``(2) Periodic investigations to determine compliance with 
     health coverage participation requirements.--The Secretary 
     shall regularly audit a representative sampling of employers 
     and conduct investigations and other activities with respect 
     to such sampling of employers so as to discover noncompliance 
     with the health coverage participation requirements in 
     connection with such employers (during any period with 
     respect to which an election under subsection (a) is in 
     effect). The Secretary shall communicate findings of 
     noncompliance made by the Secretary under this subsection to 
     the Secretary of the Treasury and the Health Choices 
     Commissioner. The Secretary shall take such timely 
     enforcement action as appropriate to achieve compliance.
       ``(3) Recordkeeping.--To facilitate the audits described in 
     subsection (b), the Secretary shall promulgate recordkeeping 
     requirements for employers to account for both employees of 
     the employer and individuals whom the employer has not 
     treated as employees of the employer but with whom the 
     employer, in the course of its trade or business, has engaged 
     for the performance of labor or services. The scope and 
     content of such recordkeeping requirements shall be 
     determined by the Secretary and shall be designed to ensure 
     that employees who are not properly treated as such may be 
     identified and properly treated.
       ``(c) Health Coverage Participation Requirements.--For 
     purposes of this section, the term `health coverage 
     participation requirements' means the requirements of part 1 
     of subtitle B of title IV of division A of the (as in effect 
     on the date of the enactment of this section).
       ``(d) Separate Elections.--Under regulations prescribed by 
     the Secretary, separate elections may be made under 
     subsection (a) with respect to full-time employees and 
     employees who are not full-time employees.
       ``(e) Termination of Election in Cases of Substantial 
     Noncompliance.--The Secretary may terminate the election of 
     any employer under subsection (a) if the Secretary (in 
     coordination with the Health Choices Commissioner) determines 
     that such employer is in substantial noncompliance with the 
     health coverage participation requirements and shall refer 
     any such determination to the Secretary of the Treasury as 
     appropriate.
       ``(f) Enforcement of Health Coverage Participation 
     Requirements.--
       ``(1) Civil penalties.--In the case of any employer who 
     fails (during any period with respect to which the election 
     under subsection (a) is in effect) to satisfy the health 
     coverage participation requirements with respect to any 
     employee, the Secretary may assess a civil penalty against 
     the employer of $100 for each day in the period beginning on 
     the date such failure first occurs and ending on the date 
     such failure is corrected.
       ``(2) Limitations on amount of penalty.--
       ``(A) Penalty not to apply where failure not discovered 
     exercising reasonable diligence.--No penalty shall be 
     assessed under paragraph (1) with respect to any failure 
     during any period for which it is established to the 
     satisfaction of the Secretary that the employer did not know, 
     or exercising reasonable diligence would not have known, that 
     such failure existed.
       ``(B) Penalty not to apply to failures corrected within 30 
     days.--No penalty shall be assessed under paragraph (1) with 
     respect to any failure if--
       ``(i) such failure was due to reasonable cause and not to 
     willful neglect, and
       ``(ii) such failure is corrected during the 30-day period 
     beginning on the 1st date that the employer knew, or 
     exercising reasonable diligence would have known, that such 
     failure existed.
       ``(C) Overall limitation for unintentional failures.--In 
     the case of failures which are due to reasonable cause and 
     not to willful neglect, the penalty assessed under paragraph 
     (1) for failures during any 1-year period shall not exceed 
     the amount equal to the lesser of--
       ``(i) 10 percent of the aggregate amount paid or incurred 
     by the employer (or predecessor employer) during the 
     preceding taxable year for group health plans, or
       ``(ii) $500,000.
       ``(3) Advance notification of failure prior to 
     assessment.--Before a reasonable time prior to the assessment 
     of any penalty under paragraph (1) with respect to any 
     failure by an employer, the Secretary shall inform the 
     employer in writing of such failure and shall provide the 
     employer information regarding efforts and procedures which 
     may be undertaken by the employer to correct such failure.
       ``(4) Actions to enforce assessments.--The Secretary may 
     bring a civil action in any District Court of the United 
     States to collect any civil penalty under this subsection.
       ``(5) Coordination with excise tax.--Under regulations 
     prescribed in accordance with section 424 of the Affordable 
     Health Care for America Act, the Secretary and the Secretary 
     of the Treasury shall coordinate the assessment of penalties 
     under paragraph (1) in connection with failures to satisfy 
     health coverage participation requirements with the 
     imposition of excise taxes on such failures under section 
     4980H(b) of the Internal Revenue Code of 1986 so as to avoid 
     duplication of penalties with respect to such failures.
       ``(6) Deposit of penalty collected.--Any amount of penalty 
     collected under this subsection shall be deposited as 
     miscellaneous receipts in the Treasury of the United States.
       ``(g) Regulations.--The Secretary may promulgate such 
     regulations as may be necessary or appropriate to carry out 
     the provisions of this section, in accordance with section 
     424(a) of the . The Secretary may promulgate any interim 
     final rules as the Secretary determines are appropriate to 
     carry out this section.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to periods beginning after December 31, 2012.

[[Page 27248]]



     SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COVERAGE 
                   PARTICIPATION REQUIREMENTS.

       (a) Assuring Coordination.--The officers consisting of the 
     Secretary of Labor, the Secretary of the Treasury, the 
     Secretary of Health and Human Services, and the Health 
     Choices Commissioner shall ensure, through the execution of 
     an interagency memorandum of understanding among such 
     officers, that--
       (1) regulations, rulings, and interpretations issued by 
     such officers relating to the same matter over which two or 
     more of such officers have responsibility under subpart B of 
     part 8 of subtitle B of title I of the Employee Retirement 
     Income Security Act of 1974, section 4980H of the Internal 
     Revenue Code of 1986, and section 2793 of the Public Health 
     Service Act are administered so as to have the same effect at 
     all times; and
       (2) coordination of policies relating to enforcing the same 
     requirements through such officers in order to have a 
     coordinated enforcement strategy that avoids duplication of 
     enforcement efforts and assigns priorities in enforcement.
       (b) Multiemployer Plans.--In the case of a group health 
     plan that is a multiemployer plan (as defined in section 
     3(37) of the Employee Retirement Income Security Act of 
     1974), the regulations prescribed in accordance with 
     subsection (a) by the officers referred to in subsection (a) 
     shall provide for the application of the health coverage 
     participation requirements to the plan sponsor and 
     contributing employers of such plan. For purposes of this 
     division, contributions made pursuant to a collective 
     bargaining agreement or other agreement to such a group 
     health plan shall be treated as amounts paid by the employer.

          TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

         Subtitle A--Provisions Relating to Health Care Reform

                     PART 1--SHARED RESPONSIBILITY

                  Subpart A--Individual Responsibility

     SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE 
                   COVERAGE.

       (a) In General.--Subchapter A of chapter 1 of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following new part:

                 ``PART VIII--HEALTH CARE RELATED TAXES

    ``subpart a. tax on individuals without acceptable health care 
                               coverage.

``Subpart A--Tax on Individuals Without Acceptable Health Care Coverage

``Sec. 59B. Tax on individuals without acceptable health care coverage.

     ``SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE 
                   COVERAGE.

       ``(a) Tax Imposed.--In the case of any individual who does 
     not meet the requirements of subsection (d) at any time 
     during the taxable year, there is hereby imposed a tax equal 
     to 2.5 percent of the excess of--
       ``(1) the taxpayer's modified adjusted gross income for the 
     taxable year, over
       ``(2) the amount of gross income specified in section 
     6012(a)(1) with respect to the taxpayer.
       ``(b) Limitations.--
       ``(1) Tax limited to average premium.--
       ``(A) In general.--The tax imposed under subsection (a) 
     with respect to any taxpayer for any taxable year shall not 
     exceed the applicable national average premium for such 
     taxable year.
       ``(B) Applicable national average premium.--
       ``(i) In general.--For purposes of subparagraph (A), the 
     `applicable national average premium' means, with respect to 
     any taxable year, the average premium (as determined by the 
     Secretary, in coordination with the Health Choices 
     Commissioner) for self-only coverage under a basic plan which 
     is offered in a Health Insurance Exchange for the calendar 
     year in which such taxable year begins.
       ``(ii) Failure to provide coverage for more than one 
     individual.--In the case of any taxpayer who fails to meet 
     the requirements of subsection (d) with respect to more than 
     one individual during the taxable year, clause (i) shall be 
     applied by substituting `family coverage' for `self-only 
     coverage'.
       ``(2) Proration for part year failures.--The tax imposed 
     under subsection (a) with respect to any taxpayer for any 
     taxable year shall not exceed the amount which bears the same 
     ratio to the amount of tax so imposed (determined without 
     regard to this paragraph and after application of paragraph 
     (1)) as--
       ``(A) the aggregate periods during such taxable year for 
     which such individual failed to meet the requirements of 
     subsection (d), bears to
       ``(B) the entire taxable year.
       ``(c) Exceptions.--
       ``(1) Dependents.--Subsection (a) shall not apply to any 
     individual for any taxable year if a deduction is allowable 
     under section 151 with respect to such individual to another 
     taxpayer for any taxable year beginning in the same calendar 
     year as such taxable year.
       ``(2) Nonresident aliens.--Subsection (a) shall not apply 
     to any individual who is a nonresident alien.
       ``(3) Individuals residing outside united states.--Any 
     qualified individual (as defined in section 911(d)) (and any 
     qualifying child residing with such individual) shall be 
     treated for purposes of this section as covered by acceptable 
     coverage during the period described in subparagraph (A) or 
     (B) of section 911(d)(1), whichever is applicable.
       ``(4) Individuals residing in possessions of the united 
     states.--Any individual who is a bona fide resident of any 
     possession of the United States (as determined under section 
     937(a)) for any taxable year (and any qualifying child 
     residing with such individual) shall be treated for purposes 
     of this section as covered by acceptable coverage during such 
     taxable year.
       ``(5) Religious conscience exemption.--
       ``(A) In general.--Subsection (a) shall not apply to any 
     individual (and any qualifying child residing with such 
     individual) for any period if such individual has in effect 
     an exemption which certifies that such individual is a member 
     of a recognized religious sect or division thereof described 
     in section 1402(g)(1) and an adherent of established tenets 
     or teachings of such sect or division as described in such 
     section.
       ``(B) Exemption.--An application for the exemption 
     described in subparagraph (A) shall be filed with the 
     Secretary at such time and in such form and manner as the 
     Secretary may prescribe. The Secretary may treat an 
     application for exemption under section 1402(g)(1) as an 
     application for exemption under this section, or may 
     otherwise coordinate applications under such sections, as the 
     Secretary determines appropriate. Any such exemption granted 
     by the Secretary shall be effective for such period as the 
     Secretary determines appropriate.
       ``(d) Acceptable Coverage Requirement.--
       ``(1) In general.--The requirements of this subsection are 
     met with respect to any individual for any period if such 
     individual (and each qualifying child of such individual) is 
     covered by acceptable coverage at all times during such 
     period.
       ``(2) Acceptable coverage.--For purposes of this section, 
     the term `acceptable coverage' means any of the following:
       ``(A) Qualified health benefits plan coverage.--Coverage 
     under a qualified health benefits plan (as defined in section 
     100(c) of the ).
       ``(B) Grandfathered health insurance coverage; coverage 
     under grandfathered employment-based health plan.--Coverage 
     under a grandfathered health insurance coverage (as defined 
     in subsection (a) of section 202 of the Affordable Health 
     Care for America Act) or under a current employment-based 
     health plan (within the meaning of subsection (b) of such 
     section).
       ``(C) Medicare.--Coverage under part A of title XVIII of 
     the Social Security Act.
       ``(D) Medicaid.--Coverage for medical assistance under 
     title XIX of the Social Security Act.
       ``(E) Members of the armed forces and dependents (including 
     tricare).--Coverage under chapter 55 of title 10, United 
     States Code, including similar coverage furnished under 
     section 1781 of title 38 of such Code.
       ``(F) VA.--Coverage under the veteran's health care program 
     under chapter 17 of title 38, United States Code.
       ``(G) Members of indian tribes.--Health care services made 
     available through the Indian Health Service, a tribal 
     organization (as defined in section 4 of the Indian Health 
     Care Improvement Act), or an urban Indian organization (as 
     defined in such section) to members of an Indian tribe (as 
     defined in such section).
       ``(H) Other coverage.--Such other health benefits coverage 
     as the Secretary, in coordination with the Health Choices 
     Commissioner, recognizes for purposes of this subsection.
       ``(e) Other Definitions and Special Rules.--
       ``(1) Qualifying child.--For purposes of this section, the 
     term `qualifying child' has the meaning given such term by 
     section 152(c). With respect to any period during which 
     health coverage for a child must be provided by an individual 
     pursuant to a child support order, such child shall be 
     treated as a qualifying child of such individual (and not as 
     a qualifying child of any other individual).
       ``(2) Basic plan.--For purposes of this section, the term 
     `basic plan' has the meaning given such term under section 
     100(c) of the Affordable Health Care for America Act.
       ``(3) Health insurance exchange.--For purposes of this 
     section, the term `Health Insurance Exchange' has the meaning 
     given such term under section 100(c) of the Affordable Health 
     Care for America Act, including any State-based health 
     insurance exchange approved for operation under section 308 
     of such Act.
       ``(4) Family coverage.--For purposes of this section, the 
     term `family coverage' means any coverage other than self-
     only coverage.
       ``(5) Modified adjusted gross income.--For purposes of this 
     section, the term `modified adjusted gross income' means 
     adjusted gross income increased by--
       ``(A) any amount excluded from gross income under section 
     911, and
       ``(B) any amount of interest received or accrued by the 
     taxpayer during the taxable year which is exempt from tax.

[[Page 27249]]

       ``(6) Not treated as tax imposed by this chapter for 
     certain purposes.--The tax imposed under this section shall 
     not be treated as tax imposed by this chapter for purposes of 
     determining the amount of any credit under this chapter or 
     for purposes of section 55.
       ``(f) Regulations.--The Secretary shall prescribe such 
     regulations or other guidance as may be necessary or 
     appropriate to carry out the purposes of this section, 
     including regulations or other guidance (developed in 
     coordination with the Health Choices Commissioner) which 
     provide--
       ``(1) exemption from the tax imposed under subsection (a) 
     in cases of de minimis lapses of acceptable coverage, and
       ``(2) a waiver of the application of subsection (a) in 
     cases of hardship, including a process for applying for such 
     a waiver.''.
       (b) Information Reporting.--
       (1) In general.--Subpart B of part III of subchapter A of 
     chapter 61 of such Code is amended by inserting after section 
     6050W the following new section:

     ``SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.

       ``(a) Requirement of Reporting.--Every person who provides 
     acceptable coverage (as defined in section 59B(d)) to any 
     individual during any calendar year shall, at such time as 
     the Secretary may prescribe, make the return described in 
     subsection (b) with respect to such individual.
       ``(b) Form and Manner of Returns.--A return is described in 
     this subsection if such return--
       ``(1) is in such form as the Secretary may prescribe, and
       ``(2) contains--
       ``(A) the name, address, and TIN of the primary insured and 
     the name of each other individual obtaining coverage under 
     the policy,
       ``(B) the period for which each such individual was 
     provided with the coverage referred to in subsection (a), and
       ``(C) such other information as the Secretary may require.
       ``(c) Statements to Be Furnished to Individuals With 
     Respect to Whom Information Is Required.--Every person 
     required to make a return under subsection (a) shall furnish 
     to each primary insured whose name is required to be set 
     forth in such return a written statement showing--
       ``(1) the name and address of the person required to make 
     such return and the phone number of the information contact 
     for such person, and
       ``(2) the information required to be shown on the return 
     with respect to such individual.
     The written statement required under the preceding sentence 
     shall be furnished on or before January 31 of the year 
     following the calendar year for which the return under 
     subsection (a) is required to be made.
       ``(d) Coverage Provided by Governmental Units.--In the case 
     of coverage provided by any governmental unit or any agency 
     or instrumentality thereof, the officer or employee who 
     enters into the agreement to provide such coverage (or the 
     person appropriately designated for purposes of this section) 
     shall make the returns and statements required by this 
     section.''.
       (2) Penalty for failure to file.--
       (A) Return.--Subparagraph (B) of section 6724(d)(1) of such 
     Code is amended by striking ``or'' at the end of clause 
     (xxii), by striking ``and'' at the end of clause (xxiii) and 
     inserting ``or'', and by adding at the end the following new 
     clause:
       ``(xxiv) section 6050X (relating to returns relating to 
     health insurance coverage), and''.
       (B) Statement.--Paragraph (2) of section 6724(d) of such 
     Code is amended by striking ``or'' at the end of subparagraph 
     (EE), by striking the period at the end of subparagraph (FF) 
     and inserting ``, or'', and by inserting after subparagraph 
     (FF) the following new subparagraph:
       ``(GG) section 6050X (relating to returns relating to 
     health insurance coverage).''.
       (c) Return Requirement.--Subsection (a) of section 6012 of 
     such Code is amended by inserting after paragraph (9) the 
     following new paragraph:
       ``(10) Every individual to whom section 59B(a) applies and 
     who fails to meet the requirements of section 59B(d) with 
     respect to such individual or any qualifying child (as 
     defined in section 152(c)) of such individual.''.
       (d) Clerical Amendments.--
       (1) The table of parts for subchapter A of chapter 1 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new item:

               ``Part VIII. Health Care Related Taxes.''.

       (2) The table of sections for subpart B of part III of 
     subchapter A of chapter 61 is amended by adding at the end 
     the following new item:

``Sec. 6050X. Returns relating to health insurance coverage.''.
       (e) Section 15 Not to Apply.--The amendment made by 
     subsection (a) shall not be treated as a change in a rate of 
     tax for purposes of section 15 of the Internal Revenue Code 
     of 1986.
       (f) Effective Date.--
       (1) In general.--The amendments made by this section shall 
     apply to taxable years beginning after December 31, 2012.
       (2) Returns.--The amendments made by subsection (b) shall 
     apply to calendar years beginning after December 31, 2012.

                   Subpart B--Employer Responsibility

     SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION 
                   REQUIREMENTS.

       (a) In General.--Chapter 43 of the Internal Revenue Code of 
     1986 is amended by adding at the end the following new 
     section:

     ``SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COVERAGE 
                   PARTICIPATION REQUIREMENTS.

       ``(a) Election of Employer Responsibility to Provide Health 
     Coverage.--
       ``(1) In general.--Subsection (b) shall apply to any 
     employer with respect to whom an election under paragraph (2) 
     is in effect.
       ``(2) Time and manner.--An employer may make an election 
     under this paragraph at such time and in such form and manner 
     as the Secretary may prescribe.
       ``(3) Affiliated groups.--In the case of any employer which 
     is part of a group of employers who are treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414, the election under paragraph (2) shall be made by such 
     person as the Secretary may provide. Any such election, once 
     made, shall apply to all members of such group.
       ``(4) Separate elections.--Under regulations prescribed by 
     the Secretary, separate elections may be made under paragraph 
     (2) with respect to--
       ``(A) separate lines of business, and
       ``(B) full-time employees and employees who are not full-
     time employees.
       ``(5) Termination of election in cases of substantial 
     noncompliance.--The Secretary may terminate the election of 
     any employer under paragraph (2) if the Secretary (in 
     coordination with the Health Choices Commissioner) determines 
     that such employer is in substantial noncompliance with the 
     health coverage participation requirements.
       ``(b) Excise Tax With Respect to Failure to Meet Health 
     Coverage Participation Requirements.--
       ``(1) In general.--In the case of any employer who fails 
     (during any period with respect to which the election under 
     subsection (a) is in effect) to satisfy the health coverage 
     participation requirements with respect to any employee to 
     whom such election applies, there is hereby imposed on each 
     such failure with respect to each such employee a tax of $100 
     for each day in the period beginning on the date such failure 
     first occurs and ending on the date such failure is 
     corrected.
       ``(2) Limitations on amount of tax.--
       ``(A) Tax not to apply where failure not discovered 
     exercising reasonable diligence.--No tax shall be imposed by 
     paragraph (1) on any failure during any period for which it 
     is established to the satisfaction of the Secretary that the 
     employer neither knew, nor exercising reasonable diligence 
     would have known, that such failure existed.
       ``(B) Tax not to apply to failures corrected within 30 
     days.--No tax shall be imposed by paragraph (1) on any 
     failure if--
       ``(i) such failure was due to reasonable cause and not to 
     willful neglect, and
       ``(ii) such failure is corrected during the 30-day period 
     beginning on the 1st date that the employer knew, or 
     exercising reasonable diligence would have known, that such 
     failure existed.
       ``(C) Overall limitation for unintentional failures.--In 
     the case of failures which are due to reasonable cause and 
     not to willful neglect, the tax imposed by subsection (a) for 
     failures during the taxable year of the employer shall not 
     exceed the amount equal to the lesser of--
       ``(i) 10 percent of the aggregate amount paid or incurred 
     by the employer (or predecessor employer) during the 
     preceding taxable year for employment-based health plans, or
       ``(ii) $500,000.
       ``(D) Coordination with other enforcement provisions.--The 
     tax imposed under paragraph (1) with respect to any failure 
     shall be reduced (but not below zero) by the amount of any 
     civil penalty collected under section 502(c)(11) of the 
     Employee Retirement Income Security Act of 1974 or section 
     2793(g) of the Public Health Service Act with respect to such 
     failure.
       ``(c) Health Coverage Participation Requirements.--For 
     purposes of this section, the term `health coverage 
     participation requirements' means the requirements of part I 
     of subtitle B of title IV of the (as in effect on the date of 
     the enactment of this section).''.
       (b) Clerical Amendment.--The table of sections for chapter 
     43 of such Code is amended by adding at the end the following 
     new item:

``Sec. 4980H. Election with respect to health coverage participation 
              requirements.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to periods beginning after December 31, 2012.

     SEC. 512. HEALTH CARE CONTRIBUTIONS OF NONELECTING EMPLOYERS.

       (a) In General.--Section 3111 of the Internal Revenue Code 
     of 1986 is amended by redesignating subsection (c) as 
     subsection (d) and by inserting after subsection (b) the 
     following new subsection:

[[Page 27250]]

       ``(c) Employers Electing Not to Provide Health Benefits.--
       ``(1) In general.--In addition to other taxes, there is 
     hereby imposed on every nonelecting employer an excise tax, 
     with respect to having individuals in his employ, equal to 8 
     percent of the wages (as defined in section 3121(a)) paid by 
     him with respect to employment (as defined in section 
     3121(b)).
       ``(2) Special rules for small employers.--
       ``(A) In general.--In the case of any employer who is small 
     employer for any calendar year, paragraph (1) shall be 
     applied by substituting the applicable percentage determined 
     in accordance with the following table for `8 percent':


``If the annual payroll of such          The applicable percentage is:
 employer for the preceding calendar
 year:
  Does not exceed $500,000.............  0 percent
  Exceeds $500,000, but does not exceed  2 percent
   $585,000.
  Exceeds $585,000, but does not exceed  4 percent
   $670,000.
  Exceeds $670,000, but does not exceed  6 percent
   $750,000.
 


       ``(B) Small employer.--For purposes of this paragraph, the 
     term `small employer' means any employer for any calendar 
     year if the annual payroll of such employer for the preceding 
     calendar year does not exceed $750,000.
       ``(C) Annual payroll.--For purposes of this paragraph, the 
     term `annual payroll' means, with respect to any employer for 
     any calendar year, the aggregate wages (as defined in section 
     3121(a)) paid by him with respect to employment (as defined 
     in section 3121(b)) during such calendar year.
       ``(3) Nonelecting employer.--For purposes of paragraph (1), 
     the term `nonelecting employer' means any employer for any 
     period with respect to which such employer does not have an 
     election under section 4980H(a) in effect.
       ``(4) Special rule for separate elections.--In the case of 
     an employer who makes a separate election described in 
     section 4980H(a)(4) for any period, paragraph (1) shall be 
     applied for such period by taking into account only the wages 
     paid to employees who are not subject to such election.
       ``(5) Aggregation; predecessors.--For purposes of this 
     subsection--
       ``(A) all persons treated as a single employer under 
     subsection (b), (c), (m), or (o) of section 414 shall be 
     treated as 1 employer, and
       ``(B) any reference to any person shall be treated as 
     including a reference to any predecessor of such person.''.
       (b) Definitions.--Section 3121 of such Code is amended by 
     adding at the end the following new subsection:
       ``(aa) Special Rules for Tax on Employers Electing Not to 
     Provide Health Benefits.--For purposes of section 3111(c)--
       ``(1) Paragraphs (1), (5), and (19) of subsection (b) shall 
     not apply.
       ``(2) Paragraph (7) of subsection (b) shall apply by 
     treating all services as not covered by the retirement 
     systems referred to in subparagraphs (C) and (F) thereof.
       ``(3) Subsection (e) shall not apply and the term `State' 
     shall include the District of Columbia.''.
       (c) Conforming Amendment.--Subsection (d) of section 3111 
     of such Code, as redesignated by this section, is amended by 
     striking ``this section'' and inserting ``subsections (a) and 
     (b)''.
       (d) Application to Railroads.--
       (1) In general.--Section 3221 of such Code is amended by 
     redesignating subsection (c) as subsection (d) and by 
     inserting after subsection (b) the following new subsection:
       ``(c) Employers Electing Not to Provide Health Benefits.--
       ``(1) In general.--In addition to other taxes, there is 
     hereby imposed on every nonelecting employer an excise tax, 
     with respect to having individuals in his employ, equal to 8 
     percent of the compensation paid during any calendar year by 
     such employer for services rendered to such employer.
       ``(2) Exception for small employers.--Rules similar to the 
     rules of section 3111(c)(2) shall apply for purposes of this 
     subsection.
       ``(3) Nonelecting employer.--For purposes of paragraph (1), 
     the term `nonelecting employer' means any employer for any 
     period with respect to which such employer does not have an 
     election under section 4980H(a) in effect.
       ``(4) Special rule for separate elections.--In the case of 
     an employer who makes a separate election described in 
     section 4980H(a)(4) for any period, subsection (a) shall be 
     applied for such period by taking into account only the 
     compensation paid to employees who are not subject to such 
     election.''.
       (2) Definitions.--Subsection (e) of section 3231 of such 
     Code is amended by adding at the end the following new 
     paragraph:
       ``(13) Special rules for tax on employers electing not to 
     provide health benefits.--For purposes of section 3221(c)--
       ``(A) Paragraph (1) shall be applied without regard to the 
     third sentence thereof.
       ``(B) Paragraph (2) shall not apply.''.
       (3) Conforming amendment.--Subsection (d) of section 3221 
     of such Code, as redesignated by this section, is amended by 
     striking ``subsections (a) and (b), see section 3231(e)(2)'' 
     and inserting ``this section, see paragraphs (2) and (13)(B) 
     of section 3231(e)''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to periods beginning after December 31, 2012.

  PART 2--CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES

     SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE 
                   EXPENSES.

       (a) In General.--Subpart D of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     business-related credits) is amended by adding at the end the 
     following new section:

     ``SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT.

       ``(a) In General.--For purposes of section 38, in the case 
     of a qualified small employer, the small business employee 
     health coverage credit determined under this section for the 
     taxable year is an amount equal to the applicable percentage 
     of the qualified employee health coverage expenses of such 
     employer for such taxable year.
       ``(b) Applicable Percentage.--
       ``(1) In general.--For purposes of this section, the 
     applicable percentage is 50 percent.
       ``(2) Phaseout based on average compensation of 
     employees.--In the case of an employer whose average annual 
     employee compensation for the taxable year exceeds $20,000, 
     the percentage specified in paragraph (1) shall be reduced by 
     a number of percentage points which bears the same ratio to 
     50 as such excess bears to $20,000.
       ``(c) Limitations.--
       ``(1) Phaseout based on employer size.--In the case of an 
     employer who employs more than 10 qualified employees during 
     the taxable year, the credit determined under subsection (a) 
     shall be reduced by an amount which bears the same ratio to 
     the amount of such credit (determined without regard to this 
     paragraph and after the application of the other provisions 
     of this section) as--
       ``(A) the excess of--
       ``(i) the number of qualified employees employed by the 
     employer during the taxable year, over
       ``(ii) 10, bears to
       ``(B) 15.
       ``(2) Credit not allowed with respect to certain highly 
     compensated employees.--No credit shall be determined under 
     subsection (a) with respect to qualified employee health 
     coverage expenses paid or incurred with respect to any 
     employee for any taxable year if the aggregate compensation 
     paid by the employer to such employee during such taxable 
     year exceeds $80,000.
       ``(3) Credit allowed for only 2 taxable years.--No credit 
     shall be determined under subsection (a) with respect to any 
     employer for any taxable year unless the employer elects to 
     have this section apply for such taxable year. An employer 
     may elect the application of this section with respect to not 
     more than 2 taxable years.
       ``(d) Qualified Employee Health Coverage Expenses.--For 
     purposes of this section--
       ``(1) In general.--The term `qualified employee health 
     coverage expenses' means, with respect to any employer for 
     any taxable year, the aggregate amount paid or incurred by 
     such employer during such taxable year for coverage of any 
     qualified employee of the employer (including any family 
     coverage which covers such employee) under qualified health 
     coverage.
       ``(2) Qualified health coverage.--The term `qualified 
     health coverage' means acceptable coverage (as defined in 
     section 59B(d)) which--
       ``(A) is provided pursuant to an election under section 
     4980H(a), and
       ``(B) satisfies the requirements referred to in section 
     4980H(c).
       ``(e) Other Definitions.--For purposes of this section--
       ``(1) Qualified small employer.--For purposes of this 
     section, the term `qualified small employer' means any 
     employer for any taxable year if--
       ``(A) the number of qualified employees employed by such 
     employer during the taxable year does not exceed 25, and
       ``(B) the average annual employee compensation of such 
     employer for such taxable year does not exceed the sum of the 
     dollar amounts in effect under subsection (b)(2).
       ``(2) Qualified employee.--The term `qualified employee' 
     means any employee of an employer for any taxable year of the 
     employer if such employee received at least $5,000 of 
     compensation from such employer

[[Page 27251]]

     for services performed in the trade or business of such 
     employer during such taxable year.
       ``(3) Average annual employee compensation.--The term 
     `average annual employee compensation' means, with respect to 
     any employer for any taxable year, the average amount of 
     compensation paid by such employer to qualified employees of 
     such employer during such taxable year.
       ``(4) Compensation.--The term `compensation' has the 
     meaning given such term in section 408(p)(6)(A).
       ``(5) Family coverage.--The term `family coverage' means 
     any coverage other than self-only coverage.
       ``(f) Special Rules.--For purposes of this section--
       ``(1) Special rule for partnerships and self-employed.--In 
     the case of a partnership (or a trade or business carried on 
     by an individual) which has one or more qualified employees 
     (determined without regard to this paragraph) with respect to 
     whom the election under section 4980H(a) applies, each 
     partner (or, in the case of a trade or business carried on by 
     an individual, such individual) shall be treated as an 
     employee.
       ``(2) Aggregation rule.--All persons treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414 shall be treated as 1 employer.
       ``(3) Predecessors.--Any reference in this section to an 
     employer shall include a reference to any predecessor of such 
     employer.
       ``(4) Denial of double benefit.--Any deduction otherwise 
     allowable with respect to amounts paid or incurred for health 
     insurance coverage to which subsection (a) applies shall be 
     reduced by the amount of the credit determined under this 
     section.
       ``(5) Inflation adjustment.--In the case of any taxable 
     year beginning after 2013, each of the dollar amounts in 
     subsections (b)(2), (c)(2), and (e)(2) shall be increased by 
     an amount equal to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost of living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins determined by substituting `calendar year 2012' 
     for `calendar year 1992' in subparagraph (B) thereof.
     If any increase determined under this paragraph is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.''.
       (b) Credit to Be Part of General Business Credit.--
     Subsection (b) of section 38 of such Code (relating to 
     general business credit) is amended by striking ``plus'' at 
     the end of paragraph (34), by striking the period at the end 
     of paragraph (35) and inserting ``, plus'' , and by adding at 
     the end the following new paragraph:
       ``(36) in the case of a qualified small employer (as 
     defined in section 45R(e)), the small business employee 
     health coverage credit determined under section 45R(a).''.
       (c) Clerical Amendment.--The table of sections for subpart 
     D of part IV of subchapter A of chapter 1 of such Code is 
     amended by inserting after the item relating to section 45Q 
     the following new item:

``Sec. 45R. Small business employee health coverage credit.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

        PART 3--LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES

     SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR 
                   PRESCRIBED DRUG OR INSULIN.

       (a) HSAs.--Subparagraph (A) of section 223(d)(2) of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following: ``Such term shall include an amount paid for 
     medicine or a drug only if such medicine or drug is a 
     prescribed drug or is insulin.''.
       (b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of 
     such Code is amended by adding at the end the following: 
     ``Such term shall include an amount paid for medicine or a 
     drug only if such medicine or drug is a prescribed drug or is 
     insulin.''.
       (c) Health Flexible Spending Arrangements and Health 
     Reimbursement Arrangements.--Section 106 of such Code is 
     amended by adding at the end the following new subsection:
       ``(f) Reimbursements for Medicine Restricted to Prescribed 
     Drugs and Insulin.--For purposes of this section and section 
     105, reimbursement for expenses incurred for a medicine or a 
     drug shall be treated as a reimbursement for medical expenses 
     only if such medicine or drug is a prescribed drug or is 
     insulin.''.
       (d) Effective Dates.--The amendment made by this section 
     shall apply to expenses incurred after December 31, 2010.

     SEC. 532. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS 
                   UNDER CAFETERIA PLANS.

       (a) In General.--Section 125 of the Internal Revenue Code 
     of 1986 is amended--
       (1) by redesignating subsections (i) and (j) as subsections 
     (j) and (k), respectively, and
       (2) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Limitation on Health Flexible Spending 
     Arrangements.--
       ``(1) In general.--For purposes of this section, if a 
     benefit is provided under a cafeteria plan through employer 
     contributions to a health flexible spending arrangement, such 
     benefit shall not be treated as a qualified benefit unless 
     the cafeteria plan provides that an employee may not elect 
     for any taxable year to have salary reduction contributions 
     in excess of $2,500 made to such arrangement.
       ``(2) Inflation adjustment.--In the case of any taxable 
     year beginning after 2013, the dollar amount in paragraph (1) 
     shall be increased by an amount equal to--
       ``(A) such dollar amount, multiplied by
       ``(B) the cost of living adjustment determined under 
     section 1(f)(3) for the calendar year in which the taxable 
     year begins determined by substituting `calendar year 2012' 
     for `calendar year 1992' in subparagraph (B) thereof.
     If any increase determined under this paragraph is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DISTRIBUTIONS 
                   FROM HEALTH SAVINGS ACCOUNTS.

       (a) In General.--Subparagraph (A) of section 223(f)(4) of 
     the Internal Revenue Code of 1986 is amended by striking ``10 
     percent'' and inserting ``20 percent''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES FOR 
                   PRESCRIPTION DRUG PLANS WHICH HAVE BEEN 
                   EXCLUDED FROM GROSS INCOME.

       (a) In General.--Section 139A of the Internal Revenue Code 
     of 1986 is amended by striking the second sentence.
       (b) Effective Date.--The amendment made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     PART 4--OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM

     SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE 
                   SUBSIDIES.

       (a) In General.--Subsection (l) of section 6103 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new paragraph:
       ``(21) Disclosure of return information to carry out health 
     insurance exchange subsidies.--
       ``(A) In general.--The Secretary, upon written request from 
     the Health Choices Commissioner or the head of a State-based 
     health insurance exchange approved for operation under 
     section 308 of the Affordable Health Care for America Act, 
     shall disclose to officers and employees of the Health 
     Choices Administration or such State-based health insurance 
     exchange, as the case may be, return information of any 
     taxpayer whose income is relevant in determining any 
     affordability credit described in subtitle C of title III of 
     the Affordable Health Care for America Act. Such return 
     information shall be limited to--
       ``(i) taxpayer identity information with respect to such 
     taxpayer,
       ``(ii) the filing status of such taxpayer,
       ``(iii) the modified adjusted gross income of such taxpayer 
     (as defined in section 59B(e)(5)),
       ``(iv) the number of dependents of the taxpayer,
       ``(v) such other information as is prescribed by the 
     Secretary by regulation as might indicate whether the 
     taxpayer is eligible for such affordability credits (and the 
     amount thereof), and
       ``(vi) the taxable year with respect to which the preceding 
     information relates or, if applicable, the fact that such 
     information is not available.
       ``(B) Restriction on use of disclosed information.--Return 
     information disclosed under subparagraph (A) may be used by 
     officers and employees of the Health Choices Administration 
     or such State-based health insurance exchange, as the case 
     may be, only for the purposes of, and to the extent necessary 
     in, establishing and verifying the appropriate amount of any 
     affordability credit described in subtitle C of title III of 
     the Affordable Health Care for America Act and providing for 
     the repayment of any such credit which was in excess of such 
     appropriate amount.''.
       (b) Procedures and Recordkeeping Related to Disclosures.--
     Paragraph (4) of section 6103(p) of such Code is amended--
       (1) by inserting ``, or any entity described in subsection 
     (l)(21),'' after ``or (20)'' in the matter preceding 
     subparagraph (A),
       (2) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (o)(1)(A),'' in subparagraph (F)(ii), 
     and
       (3) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (20),'' both places it appears in the 
     matter after subparagraph (F).
       (c) Unauthorized Disclosure or Inspection.--Paragraph (2) 
     of section 7213(a) of such Code is amended by striking ``or 
     (20)'' and inserting ``(20), or (21)''.

[[Page 27252]]



     SEC. 542. OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS 
                   PLANS THROUGH CAFETERIA PLANS.

       (a) In General.--Subsection (f) of section 125 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new paragraph:
       ``(3) Certain exchange-participating health benefits plans 
     not qualified.--
       ``(A) In general.--The term `qualified benefit' shall not 
     include any exchange-participating health benefits plan (as 
     defined in section 101(c) of the Affordable Health Care for 
     America Act).
       ``(B) Exception for exchange-eligible employers.--
     Subparagraph (A) shall not apply with respect to any employee 
     if such employee's employer is an exchange-eligible employer 
     (as defined in section 302 of the Affordable Health Care for 
     America Act).''.
       (b) Conforming Amendments.--Subsection (f) of section 125 
     of such Code is amended--
       (1) by striking ``For purposes of this section, the term'' 
     and inserting ``For purposes of this section--
       ``(1) In General.--The term'', and
       (2) by striking ``Such term shall not include'' and 
     inserting the following:
       ``(2) Long-term care insurance not qualified.--The term 
     `qualified benefit' shall not include''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2012.

     SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS MADE UNDER 
                   REINSURANCE PROGRAM FOR RETIREES.

       (a) In General.--Section 139A of the Internal Revenue Code 
     of 1986 is amended--
       (1) by striking ``Gross income'' and inserting the 
     following:
       ``(a) Federal Subsidies for Prescription Drug Plans.--Gross 
     income'', and
       (2) by adding at the end the following new subsection:
       ``(b) Federal Reinsurance Program for Retirees.--A rule 
     similar to the rule of subsection (a) shall apply with 
     respect to payments made under section 111 of the Affordable 
     Health Care for America Act.''.
       (b) Conforming Amendment.--The heading of section 139A of 
     such Code (and the item relating to such section in the table 
     of sections for part III of subchapter B of chapter 1 of such 
     Code) is amended by inserting ``AND RETIREE HEALTH PLANS'' 
     after ``PRESCRIPTION DRUG PLANS''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after the date of the 
     enactment of this Act.

     SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS LONG-TERM 
                   CARE INSURANCE.

       (a) In General.--Subsection (f) of section 7702B of the 
     Internal Revenue Code of 1986 is amended--
       (1) by striking ``State long-term care plan'' in paragraph 
     (1)(A) and inserting ``government long-term care plan'',
       (2) by redesignating paragraph (2) as paragraph (3), and
       (3) by inserting after paragraph (2) the following new 
     paragraph:
       ``(2) Government long-term care plan.--For purposes of this 
     subsection, the term `government long-term care plan' means--
       ``(A) the CLASS program established under title XXXII of 
     the Public Health Service Act, and
       ``(B) any State long-term care plan.''.
       (b) Conforming Amendments.--
       (1) Paragraph (3) of section 7702B(f) of such Code, as 
     redesignated by subsection (a), is amended by striking 
     ``paragraph (1)'' and inserting ``this subsection''.
       (2) Subsection (f) of section 7702(B) of such Code is 
     amended by striking ``State-maintained'' in the heading 
     thereof and inserting ``Government''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after December 31, 2010.

     SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL CARE 
                   PROVIDED FOR INDIANS.

       (a) In General.--Part III of subchapter B of chapter 1 of 
     the Internal Revenue Code of 1986 (relating to items 
     specifically excluded from gross income) is amended by 
     inserting after section 139C the following new section:

     ``SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS.

       ``(a) In General.--Gross income does not include--
       ``(1) health services or benefits provided or purchased by 
     the Indian Health Service, either directly or indirectly, 
     through a grant to or a contract or compact with an Indian 
     tribe or tribal organization or through programs of third 
     parties funded by the Indian Health Service,
       ``(2) medical care provided by an Indian tribe or tribal 
     organization to a member of an Indian tribe (including for 
     this purpose, to the member's spouse or dependents) through 
     any one of the following: provided or purchased medical care 
     services; accident or health insurance (or an arrangement 
     having the effect of accident or health insurance); or 
     amounts paid, directly or indirectly, to reimburse the member 
     for expenses incurred for medical care,
       ``(3) the value of accident or health plan coverage 
     provided by an Indian tribe or tribal organization for 
     medical care to a member of an Indian tribe (including for 
     this purpose, coverage that extends to such member's spouse 
     or dependents) under an accident or health plan (or through 
     an arrangement having the effect of accident or health 
     insurance), and
       ``(4) any other medical care provided by an Indian tribe 
     that supplements, replaces, or substitutes for the programs 
     and services provided by the Federal Government to Indian 
     tribes or Indians.
       ``(b) Definitions.--For purposes of this section--
       ``(1) In general.--The terms `accident or health insurance' 
     and `accident or health plan' have the same meaning as when 
     used in sections 104 and 106.
       ``(2) Medical care.--The term `medical care' has the 
     meaning given such term in section 213.
       ``(3) Dependent.--The term `dependent' has the meaning 
     given such term in section 152, determined without regard to 
     subsections (b)(1), (b)(2), and (d)(1)(B).
       ``(4) Indian tribe.--The term `Indian tribe' means any 
     Indian tribe, band, nation, pueblo, or other organized group 
     or community, including any Alaska Native village, or 
     regional or village corporation, as defined in, or 
     established pursuant to, the Alaska Native Claims Settlement 
     Act (43 U.S.C. 1601 et seq.), which is recognized as eligible 
     for the special programs and services provided by the United 
     States to Indians because of their status as Indians.
       ``(5) Tribal organization.--The term `tribal organization' 
     has the meaning given such term in section 4(l) of the Indian 
     Self-Determination and Education Assistance Act (25 U.S.C. 
     450b(l)).''.
       (b) Clerical Amendment.--The table of sections for such 
     part III is amended by inserting after the item relating to 
     section 139C the following new item:

``Sec. 139D. Medical care provided for Indians.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to health benefits and coverage provided after 
     the date of enactment of this Act.
       (d) No Inference.--Nothing in the amendments made by this 
     section shall be construed to create an inference with 
     respect to the exclusion from gross income of--
       (1) benefits provided by Indian tribes that are not within 
     the scope of this section, and
       (2) health benefits or coverage provided by Indian tribes 
     prior to the effective date of this section.

                  Subtitle B--Other Revenue Provisions

                       PART 1--GENERAL PROVISIONS

     SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS.

       (a) In General.--Part VIII of subchapter A of chapter 1 of 
     the Internal Revenue Code of 1986, as added by this title, is 
     amended by adding at the end the following new subpart:

           ``Subpart B--Surcharge on High Income Individuals

``Sec. 59C. Surcharge on high income individuals.

     ``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

       ``(a) General Rule.--In the case of a taxpayer other than a 
     corporation, there is hereby imposed (in addition to any 
     other tax imposed by this subtitle) a tax equal to 5.4 
     percent of so much of the modified adjusted gross income of 
     the taxpayer as exceeds $1,000,000.
       ``(b) Taxpayers Not Making a Joint Return.--In the case of 
     any taxpayer other than a taxpayer making a joint return 
     under section 6013 or a surviving spouse (as defined in 
     section 2(a)), subsection (a) shall be applied by 
     substituting `$500,000' for `$1,000,000'.
       ``(c) Modified Adjusted Gross Income.--For purposes of this 
     section, the term `modified adjusted gross income' means 
     adjusted gross income reduced by any deduction (not taken 
     into account in determining adjusted gross income) allowed 
     for investment interest (as defined in section 163(d)). In 
     the case of an estate or trust, adjusted gross income shall 
     be determined as provided in section 67(e).
       ``(d) Special Rules.--
       ``(1) Nonresident alien.--In the case of a nonresident 
     alien individual, only amounts taken into account in 
     connection with the tax imposed under section 871(b) shall be 
     taken into account under this section.
       ``(2) Citizens and residents living abroad.--The dollar 
     amount in effect under subsection (a) (after the application 
     of subsection (b)) shall be decreased by the excess of--
       ``(A) the amounts excluded from the taxpayer's gross income 
     under section 911, over
       ``(B) the amounts of any deductions or exclusions 
     disallowed under section 911(d)(6) with respect to the 
     amounts described in subparagraph (A).
       ``(3) Charitable trusts.--Subsection (a) shall not apply to 
     a trust all the unexpired interests in which are devoted to 
     one or more of the purposes described in section 
     170(c)(2)(B).
       ``(4) Not treated as tax imposed by this chapter for 
     certain purposes.--The tax imposed under this section shall 
     not be treated as tax imposed by this chapter for purposes of 
     determining the amount of any credit under this chapter or 
     for purposes of section 55.''.
       (b) Clerical Amendment.--The table of subparts for part 
     VIII of subchapter A of

[[Page 27253]]

     chapter 1 of such Code, as added by this title, is amended by 
     inserting after the item relating to subpart A the following 
     new item:

         ``subpart b. surcharge on high income individuals.''.

       (c) Section 15 Not to Apply.--The amendment made by 
     subsection (a) shall not be treated as a change in a rate of 
     tax for purposes of section 15 of the Internal Revenue Code 
     of 1986.
       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 552. EXCISE TAX ON MEDICAL DEVICES.

       (a) In General.--Chapter 31 of the Internal Revenue Code of 
     1986 is amended by adding at the end the following new 
     subchapter:

                    ``Subchapter D--Medical Devices

``Sec. 4061. Medical devices.

     ``SEC. 4061. MEDICAL DEVICES.

       ``(a) In General.--There is hereby imposed on the first 
     taxable sale of any medical device a tax equal to 2.5 percent 
     of the price for which so sold.
       ``(b) First Taxable Sale.--For purposes of this section--
       ``(1) In general.--The term `first taxable sale' means the 
     first sale, for a purpose other than for resale, after 
     production, manufacture, or importation.
       ``(2) Exception for sales at retail establishments.--Such 
     term shall not include the sale of any medical device if--
       ``(A) such sale is made at a retail establishment on terms 
     which are available to the general public, and
       ``(B) such medical device is of a type (and purchased in a 
     quantity) which is purchased by the general public.
       ``(3) Exception for exports, etc.--Rules similar to the 
     rules of sections 4221 (other than paragraphs (3), (4), (5), 
     and (6) of subsection (a) thereof) and 4222 shall apply for 
     purposes of this section. To the extent provided by the 
     Secretary, section 4222 may be extended to, and made 
     applicable with respect to, the exemption provided by 
     paragraph (2).
       ``(4) Sales to patients not treated as resales.--If a 
     medical device is sold for use in connection with providing 
     any health care service to an individual, such sale shall not 
     be treated as being for the purpose of resale (even if such 
     device is sold to such individual).
       ``(c) Other Definitions and Special Rules.--For purposes of 
     this section--
       ``(1) Medical device.--The term `medical device' means any 
     device (as defined in section 201(h) of the Federal Food, 
     Drug, and Cosmetic Act) intended for humans.
       ``(2) Lease treated as sale.--Rules similar to the rules of 
     section 4217 shall apply.
       ``(3) Use treated as sale.--
       ``(A) In general.--If any person uses a medical device 
     before the first taxable sale of such device, then such 
     person shall be liable for tax under such subsection in the 
     same manner as if such use were the first taxable sale of 
     such device.
       ``(B) Exceptions.--The preceding sentence shall not apply 
     to--
       ``(i) use of a medical device as material in the 
     manufacture or production of, or as a component part of, 
     another medical device to be manufactured or produced by such 
     person, or
       ``(ii) use of a medical device after a sale described in 
     subsection (b)(2).
       ``(4) Determination of price.--
       ``(A) In general.--Rules similar to the rules of 
     subsections (a), (c), and (d) of section 4216 shall apply for 
     purposes of this section.
       ``(B) Constructive sale price.--If--
       ``(i) a medical device is sold (otherwise than through an 
     arm's length transaction) at less than the fair market price, 
     or
       ``(ii) a person is liable for tax for a use described in 
     paragraph (3),
     the tax under this section shall be computed on the price for 
     which such or similar devices are sold in the ordinary course 
     of trade as determined by the Secretary.
       ``(5) Resales pursuant to certain contract arrangements.--
       ``(A) In general.--In the case of a specified contract sale 
     of a medical device, the seller referred to in subparagraph 
     (B)(i) shall be entitled to recover from the producer, 
     manufacturer, or importer referred to in subparagraph (B)(ii) 
     the amount of the tax paid by such seller under this section 
     with respect to such sale.
       ``(B) Specified contract sale.--For purposes of this 
     paragraph, the term `specified contract sale' means, with 
     respect to any medical device, the first taxable sale of such 
     device if--
       ``(i) the seller is not the producer, manufacturer, or 
     importer of such device, and
       ``(ii) the price at which such device is so sold is 
     determined in accordance with a contract between the 
     producer, manufacturer, or importer of such device and the 
     person to whom such device is so sold.
       ``(C) Special rules related to credits and refunds.--In the 
     case of any credit or refund under section 6416 of the tax 
     imposed under this section on a specified contract sale of a 
     medical device--
       ``(i) such credit or refund shall be allowed or made only 
     if the seller has filed with the Secretary the written 
     consent of the producer, manufacturer, or importer referred 
     to in subparagraph (B)(ii) to the allowance of such credit or 
     the making of such refund, and
       ``(ii) the amount of tax taken into account under 
     subparagraph (A) shall be reduced by the amount of such 
     credit or refund.''.
       (b) Conforming Amendments.--
       (1) Paragraph (2) of section 6416(b) of such Code is 
     amended--
       (A) by inserting ``or 4061'' after ``under section 4051'', 
     and
       (B) by adding at the end the following: ``In the case of 
     the tax imposed by section 4061, subparagraphs (B), (C), (D), 
     and (E) shall not apply.''.
       (2) The table of subchapters for chapter 31 of such Code is 
     amended by adding at the end the following new item:

                  ``subchapter d. medical devices.''.

       (c) Effective Date.--The amendments made by this section 
     shall apply to sales (and leases and uses treated as sales) 
     after December 31, 2012.

     SEC. 553. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.

       (a) In General.--Section 6041 of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subsections:
       ``(h) Application to Corporations.--Notwithstanding any 
     regulation prescribed by the Secretary before the date of the 
     enactment of this subsection, for purposes of this section 
     the term `person' includes any corporation that is not an 
     organization exempt from tax under section 501(a).
       ``(i) Regulations.--The Secretary may prescribe such 
     regulations and other guidance as may be appropriate or 
     necessary to carry out the purposes of this section, 
     including rules to prevent duplicative reporting of 
     transactions.''.
       (b) Payments for Property and Other Gross Proceeds.--
     Subsection (a) of section 6041 of the Internal Revenue Code 
     of 1986 is amended--
       (1) by inserting ``amounts in consideration for property,'' 
     after ``wages,'',
       (2) by inserting ``gross proceeds,'' after ``emoluments, or 
     other'', and
       (3) by inserting ``gross proceeds,'' after ``setting forth 
     the amount of such''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to payments made after December 31, 2011.

     SEC. 554. REPEAL OF WORLDWIDE ALLOCATION OF INTEREST.

       (a) In General.--Section 864 of the Internal Revenue Code 
     of 1986 is amended by striking subsection (f) and by 
     redesignating subsection (g) as subsection (f).
       (b) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2010.

     SEC. 555. EXCLUSION OF UNPROCESSED FUELS FROM THE CELLULOSIC 
                   BIOFUEL PRODUCER CREDIT.

       (a) In General.--Subparagraph (E) of section 40(b)(6) of 
     the Internal Revenue Code of 1986 is amended by adding at the 
     end the following new clause:
       ``(iii) Exclusion of unprocessed fuels.--The term 
     `cellulosic biofuel' shall not include any fuel if--
       ``(I) more than 4 percent of such fuel (determined by 
     weight) is any combination of water and sediment, or
       ``(II) the ash content of such fuel is more than 1 percent 
     (determined by weight).''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to fuels sold or used after the date of the 
     enactment of this Act.

                  PART 2--PREVENTION OF TAX AVOIDANCE

     SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN 
                   DEDUCTIBLE PAYMENTS.

       (a) In General.--Section 894 of the Internal Revenue Code 
     of 1986 (relating to income affected by treaty) is amended by 
     adding at the end the following new subsection:
       ``(d) Limitation on Treaty Benefits for Certain Deductible 
     Payments.--
       ``(1) In general.--In the case of any deductible related-
     party payment, any withholding tax imposed under chapter 3 
     (and any tax imposed under subpart A or B of this part) with 
     respect to such payment may not be reduced under any treaty 
     of the United States unless any such withholding tax would be 
     reduced under a treaty of the United States if such payment 
     were made directly to the foreign parent corporation.
       ``(2) Deductible related-party payment.--For purposes of 
     this subsection, the term `deductible related-party payment' 
     means any payment made, directly or indirectly, by any person 
     to any other person if the payment is allowable as a 
     deduction under this chapter and both persons are members of 
     the same foreign controlled group of entities.
       ``(3) Foreign controlled group of entities.--For purposes 
     of this subsection--
       ``(A) In general.--The term `foreign controlled group of 
     entities' means a controlled group of entities the common 
     parent of which is a foreign corporation.
       ``(B) Controlled group of entities.--The term `controlled 
     group of entities' means a controlled group of corporations 
     as defined in section 1563(a)(1), except that--
       ``(i) `more than 50 percent' shall be substituted for `at 
     least 80 percent' each place it appears therein, and
       ``(ii) the determination shall be made without regard to 
     subsections (a)(4) and (b)(2) of section 1563.
     A partnership or any other entity (other than a corporation) 
     shall be treated as a

[[Page 27254]]

     member of a controlled group of entities if such entity is 
     controlled (within the meaning of section 954(d)(3)) by 
     members of such group (including any entity treated as a 
     member of such group by reason of this sentence).
       ``(4) Foreign parent corporation.--For purposes of this 
     subsection, the term `foreign parent corporation' means, with 
     respect to any deductible related-party payment, the common 
     parent of the foreign controlled group of entities referred 
     to in paragraph (3)(A).
       ``(5) Regulations.--The Secretary may prescribe such 
     regulations or other guidance as are necessary or appropriate 
     to carry out the purposes of this subsection, including 
     regulations or other guidance which provide for--
       ``(A) the treatment of two or more persons as members of a 
     foreign controlled group of entities if such persons would be 
     the common parent of such group if treated as one 
     corporation, and
       ``(B) the treatment of any member of a foreign controlled 
     group of entities as the common parent of such group if such 
     treatment is appropriate taking into account the economic 
     relationships among such entities.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to payments made after the date of the enactment 
     of this Act.

     SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE; 
                   PENALTIES.

       (a) In General.--Section 7701 of the Internal Revenue Code 
     of 1986 is amended by redesignating subsection (o) as 
     subsection (p) and by inserting after subsection (n) the 
     following new subsection:
       ``(o) Clarification of Economic Substance Doctrine.--
       ``(1) Application of doctrine.--In the case of any 
     transaction to which the economic substance doctrine is 
     relevant, such transaction shall be treated as having 
     economic substance only if--
       ``(A) the transaction changes in a meaningful way (apart 
     from Federal income tax effects) the taxpayer's economic 
     position, and
       ``(B) the taxpayer has a substantial purpose (apart from 
     Federal income tax effects) for entering into such 
     transaction.
       ``(2) Special rule where taxpayer relies on profit 
     potential.--
       ``(A) In general.--The potential for profit of a 
     transaction shall be taken into account in determining 
     whether the requirements of subparagraphs (A) and (B) of 
     paragraph (1) are met with respect to the transaction only if 
     the present value of the reasonably expected pre-tax profit 
     from the transaction is substantial in relation to the 
     present value of the expected net tax benefits that would be 
     allowed if the transaction were respected.
       ``(B) Treatment of fees and foreign taxes.--Fees and other 
     transaction expenses and foreign taxes shall be taken into 
     account as expenses in determining pre-tax profit under 
     subparagraph (A).
       ``(3) State and local tax benefits.--For purposes of 
     paragraph (1), any State or local income tax effect which is 
     related to a Federal income tax effect shall be treated in 
     the same manner as a Federal income tax effect.
       ``(4) Financial accounting benefits.--For purposes of 
     paragraph (1)(B), achieving a financial accounting benefit 
     shall not be taken into account as a purpose for entering 
     into a transaction if the origin of such financial accounting 
     benefit is a reduction of Federal income tax.
       ``(5) Definitions and special rules.--For purposes of this 
     subsection--
       ``(A) Economic substance doctrine.--The term `economic 
     substance doctrine' means the common law doctrine under which 
     tax benefits under subtitle A with respect to a transaction 
     are not allowable if the transaction does not have economic 
     substance or lacks a business purpose.
       ``(B) Exception for personal transactions of individuals.--
     In the case of an individual, paragraph (1) shall apply only 
     to transactions entered into in connection with a trade or 
     business or an activity engaged in for the production of 
     income.
       ``(C) Other common law doctrines not affected.--Except as 
     specifically provided in this subsection, the provisions of 
     this subsection shall not be construed as altering or 
     supplanting any other rule of law, and the requirements of 
     this subsection shall be construed as being in addition to 
     any such other rule of law.
       ``(D) Determination of application of doctrine not 
     affected.--The determination of whether the economic 
     substance doctrine is relevant to a transaction (or series of 
     transactions) shall be made in the same manner as if this 
     subsection had never been enacted.
       ``(6) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary or appropriate to carry out 
     the purposes of this subsection.''.
       (b) Penalty for Underpayments Attributable to Transactions 
     Lacking Economic Substance.--
       (1) In general.--Subsection (b) of section 6662 of such 
     Code is amended by inserting after paragraph (5) the 
     following new paragraph:
       ``(6) Any disallowance of claimed tax benefits by reason of 
     a transaction lacking economic substance (within the meaning 
     of section 7701(o)) or failing to meet the requirements of 
     any similar rule of law.''.
       (2) Increased penalty for nondisclosed transactions.--
     Section 6662 of such Code is amended by adding at the end the 
     following new subsection:
       ``(i) Increase in Penalty in Case of Nondisclosed 
     Noneconomic Substance Transactions.--
       ``(1) In general.--In the case of any portion of an 
     underpayment which is attributable to one or more 
     nondisclosed noneconomic substance transactions, subsection 
     (a) shall be applied with respect to such portion by 
     substituting `40 percent' for `20 percent'.
       ``(2) Nondisclosed noneconomic substance transactions.--For 
     purposes of this subsection, the term `nondisclosed 
     noneconomic substance transaction' means any portion of a 
     transaction described in subsection (b)(6) with respect to 
     which the relevant facts affecting the tax treatment are not 
     adequately disclosed in the return nor in a statement 
     attached to the return.
       ``(3) Special rule for amended returns.--Except as provided 
     in regulations, in no event shall any amendment or supplement 
     to a return of tax be taken into account for purposes of this 
     subsection if the amendment or supplement is filed after the 
     earlier of the date the taxpayer is first contacted by the 
     Secretary regarding the examination of the return or such 
     other date as is specified by the Secretary.''.
       (3) Conforming amendment.--Subparagraph (B) of section 
     6662A(e)(2) of such Code is amended--
       (A) by striking ``section 6662(h)'' and inserting 
     ``subsections (h) or (i) of section 6662'', and
       (B) by striking ``gross valuation misstatement penalty'' in 
     the heading and inserting ``certain increased underpayment 
     penalties''.
       (c) Reasonable Cause Exception Not Applicable to 
     Noneconomic Substance Transactions and Tax Shelters.--
       (1) Reasonable cause exception for underpayments.--
     Subsection (c) of section 6664 of such Code is amended--
       (A) by redesignating paragraphs (2) and (3) as paragraphs 
     (3) and (4), respectively,
       (B) by striking ``paragraph (2)'' in paragraph (4)(A), as 
     so redesignated, and inserting ``paragraph (3)'', and
       (C) by inserting after paragraph (1) the following new 
     paragraph:
       ``(2) Exception.--Paragraph (1) shall not apply to any 
     portion of an underpayment which is attributable to one or 
     more tax shelters (as defined in section 6662(d)(2)(C)) or 
     transactions described in section 6662(b)(6).''.
       (2) Reasonable cause exception for reportable transaction 
     understatements.--Subsection (d) of section 6664 of such Code 
     is amended--
       (A) by redesignating paragraphs (2) and (3) as paragraphs 
     (3) and (4), respectively,
       (B) by striking ``paragraph (2)(C)'' in paragraph (4), as 
     so redesignated, and inserting ``paragraph (3)(C)'', and
       (C) by inserting after paragraph (1) the following new 
     paragraph:
       ``(2) Exception.--Paragraph (1) shall not apply to any 
     portion of a reportable transaction understatement which is 
     attributable to one or more tax shelters (as defined in 
     section 6662(d)(2)(C)) or transactions described in section 
     6662(b)(6).''.
       (d) Application of Penalty for Erroneous Claim for Refund 
     or Credit to Noneconomic Substance Transactions.--Section 
     6676 of such Code is amended by redesignating subsection (c) 
     as subsection (d) and inserting after subsection (b) the 
     following new subsection:
       ``(c) Noneconomic Substance Transactions Treated as Lacking 
     Reasonable Basis.--For purposes of this section, any 
     excessive amount which is attributable to any transaction 
     described in section 6662(b)(6) shall not be treated as 
     having a reasonable basis.''.
       (e) Effective Date.--
       (1) In general.--Except as otherwise provided in this 
     subsection, the amendments made by this section shall apply 
     to transactions entered into after the date of the enactment 
     of this Act.
       (2) Underpayments.--The amendments made by subsections (b) 
     and (c)(1) shall apply to underpayments attributable to 
     transactions entered into after the date of the enactment of 
     this Act.
       (3) Understatements.--The amendments made by subsection 
     (c)(2) shall apply to understatements attributable to 
     transactions entered into after the date of the enactment of 
     this Act.
       (4) Refunds and credits.--The amendment made by subsection 
     (d) shall apply to refunds and credits attributable to 
     transactions entered into after the date of the enactment of 
     this Act.

     SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS MADE 
                   SUBJECT TO A MORE LIKELY THAN NOT STANDARD FOR 
                   AVOIDING PENALTIES ON UNDERPAYMENTS.

       (a) In General.--Subsection (c) of section 6664 of the 
     Internal Revenue Code of 1986, as amended by section 562, is 
     amended--
       (1) by redesignating paragraphs (3) and (4) as paragraphs 
     (4) and (5), respectively,
       (2) by striking ``paragraph (3)'' in paragraph (4)(A), as 
     so redesignated, and inserting ``paragraph (4)'', and

[[Page 27255]]

       (3) by inserting after paragraph (2) the following new 
     paragraph:
       ``(3) Special rule for certain large or publicly traded 
     persons.--
       ``(A) In general.--In the case of any specified person, 
     paragraph (1) shall apply to the portion of an underpayment 
     which is attributable to any item only if such person has a 
     reasonable belief that the tax treatment of such item by such 
     person is more likely than not the proper tax treatment of 
     such item.
       ``(B) Specified person.--For purposes of this paragraph, 
     the term `specified person' means--
       ``(i) any person required to file periodic or other reports 
     under section 13 of the Securities Exchange Act of 1934, and
       ``(ii) any corporation with gross receipts in excess of 
     $100,000,000 for the taxable year involved.

     All persons treated as a single employer under section 52(a) 
     shall be treated as one person for purposes of clause 
     (ii).''.
       (b) Nonapplication of Substantial Authority and Reasonable 
     Basis Standards for Reducing Understatements.--Paragraph (2) 
     of section 6662(d) of such Code is amended by adding at the 
     end the following new subparagraph:
       ``(D) Reduction not to apply to certain large or publicly 
     traded persons.--Subparagraph (B) shall not apply to any 
     specified person (as defined in section 6664(c)(3)(B)).''.
       (c) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by this section shall apply to underpayments 
     attributable to transactions entered into after the date of 
     the enactment of this Act.
       (2) Nonapplication of understatement reduction.--The 
     amendment made by subsection (b) shall apply to 
     understatements attributable to transactions entered into 
     after the date of the enactment of this Act.

                   PART 3--PARITY IN HEALTH BENEFITS

     SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICABLE TO 
                   SPOUSES AND DEPENDENTS EXTENDED TO ELIGIBLE 
                   BENEFICIARIES.

       (a) Application of Accident and Health Plans to Eligible 
     Beneficiaries.--
       (1) Exclusion of contributions.--Section 106 of the 
     Internal Revenue Code of 1986 (relating to contributions by 
     employer to accident and health plans), as amended by section 
     531, is amended by adding at the end the following new 
     subsection:
       ``(g) Coverage Provided for Eligible Beneficiaries of 
     Employees.--
       ``(1) In general.--Subsection (a) shall apply with respect 
     to any eligible beneficiary of the employee.
       ``(2) Eligible beneficiary.--For purposes of this 
     subsection, the term `eligible beneficiary' means any 
     individual who is eligible to receive benefits or coverage 
     under an accident or health plan.''.
       (2) Exclusion of amounts expended for medical care.--The 
     first sentence of section 105(b) of such Code (relating to 
     amounts expended for medical care) is amended--
       (A) by striking ``and his dependents'' and inserting ``his 
     dependents'', and
       (B) by inserting before the period the following: ``and any 
     eligible beneficiary (within the meaning of section 106(g)) 
     with respect to the taxpayer''.
       (3) Payroll taxes.--
       (A) Section 3121(a)(2) of such Code is amended--
       (i) by striking ``or any of his dependents'' in the matter 
     preceding subparagraph (A) and inserting ``, any of his 
     dependents, or any eligible beneficiary (within the meaning 
     of section 106(g)) with respect to the employee'',
       (ii) by striking ``or any of his dependents,'' in 
     subparagraph (A) and inserting ``, any of his dependents, or 
     any eligible beneficiary (within the meaning of section 
     106(g)) with respect to the employee,'', and
       (iii) by striking ``and their dependents'' both places it 
     appears and inserting ``and such employees' dependents and 
     eligible beneficiaries (within the meaning of section 
     106(g))''.
       (B) Section 3231(e)(1) of such Code is amended--
       (i) by striking ``or any of his dependents'' and inserting 
     ``, any of his dependents, or any eligible beneficiary 
     (within the meaning of section 106(g)) with respect to the 
     employee,'', and
       (ii) by striking ``and their dependents'' both places it 
     appears and inserting ``and such employees' dependents and 
     eligible beneficiaries (within the meaning of section 
     106(g))''.
       (C) Section 3306(b)(2) of such Code is amended--
       (i) by striking ``or any of his dependents'' in the matter 
     preceding subparagraph (A) and inserting ``, any of his 
     dependents, or any eligible beneficiary (within the meaning 
     of section 106(g)) with respect to the employee,'',
       (ii) by striking ``or any of his dependents'' in 
     subparagraph (A) and inserting ``, any of his dependents, or 
     any eligible beneficiary (within the meaning of section 
     106(g)) with respect to the employee'', and
       (iii) by striking ``and their dependents'' both places it 
     appears and inserting ``and such employees' dependents and 
     eligible beneficiaries (within the meaning of section 
     106(g))''.
       (D) Section 3401(a) of such Code is amended by striking 
     ``or'' at the end of paragraph (22), by striking the period 
     at the end of paragraph (23) and inserting ``; or'', and by 
     inserting after paragraph (23) the following new paragraph:
       ``(24) for any payment made to or for the benefit of an 
     employee or any eligible beneficiary (within the meaning of 
     section 106(g)) if at the time of such payment it is 
     reasonable to believe that the employee will be able to 
     exclude such payment from income under section 106 or under 
     section 105 by reference in section 105(b) to section 
     106(g).''.
       (b) Expansion of Dependency for Purposes of Deduction for 
     Health Insurance Costs of Self-employed Individuals.--
       (1) In general.--Paragraph (1) of section 162(l) of the 
     Internal Revenue Code of 1986 (relating to special rules for 
     health insurance costs of self-employed individuals) is 
     amended to read as follows:
       ``(1) Allowance of deduction.--In the case of a taxpayer 
     who is an employee within the meaning of section 401(c)(1), 
     there shall be allowed as a deduction under this section an 
     amount equal to the amount paid during the taxable year for 
     insurance which constitutes medical care for--
       ``(A) the taxpayer,
       ``(B) the taxpayer's spouse,
       ``(C) the taxpayer's dependents,
       ``(D) any individual who--
       ``(i) satisfies the age requirements of section 
     152(c)(3)(A),
       ``(ii) bears a relationship to the taxpayer described in 
     section 152(d)(2)(H), and
       ``(iii) meets the requirements of section 152(d)(1)(C), and
       ``(E) one individual who--
       ``(i) does not satisfy the age requirements of section 
     152(c)(3)(A),
       ``(ii) bears a relationship to the taxpayer described in 
     section 152(d)(2)(H),
       ``(iii) meets the requirements of section 152(d)(1)(D), and
       ``(iv) is not the spouse of the taxpayer and does not bear 
     any relationship to the taxpayer described in subparagraphs 
     (A) through (G) of section 152(d)(2).''.
       (2) Conforming amendment.--Subparagraph (B) of section 
     162(l)(2) of such Code is amended by inserting ``, any 
     dependent, or individual described in subparagraph (D) or (E) 
     of paragraph (1) with respect to'' after ``spouse''.
       (c) Extension to Eligible Beneficiaries of Sick and 
     Accident Benefits Provided to Members of a Voluntary 
     Employees' Beneficiary Association and Their Dependents.--
     Section 501(c)(9) of the Internal Revenue Code of 1986 
     (relating to list of exempt organizations) is amended by 
     adding at the end the following new sentence: ``For purposes 
     of providing for the payment of sick and accident benefits to 
     members of such an association and their dependents, the term 
     `dependents' shall include any individual who is an eligible 
     beneficiary (within the meaning of section 106(g)), as 
     determined under the terms of a medical benefit, health 
     insurance, or other program under which members and their 
     dependents are entitled to sick and accident benefits.''.
       (d) Flexible Spending Arrangements and Health Reimbursement 
     Arrangements.--The Secretary of Treasury shall issue guidance 
     of general applicability providing that medical expenses that 
     otherwise qualify--
       (1) for reimbursement from a flexible spending arrangement 
     under regulations in effect on the date of the enactment of 
     this Act may be reimbursed from an employee's flexible 
     spending arrangement, notwithstanding the fact that such 
     expenses are attributable to any individual who is not the 
     employee's spouse or dependent (within the meaning of section 
     105(b) of the Internal Revenue Code of 1986) but is an 
     eligible beneficiary (within the meaning of section 106(g) of 
     such Code) under the flexible spending arrangement with 
     respect to the employee, and
       (2) for reimbursement from a health reimbursement 
     arrangement under regulations in effect on the date of the 
     enactment of this Act may be reimbursed from an employee's 
     health reimbursement arrangement, notwithstanding the fact 
     that such expenses are attributable to an individual who is 
     not a spouse or dependent (within the meaning of section 
     105(b) of such Code) but is an eligible beneficiary (within 
     the meaning of section 106(g) of such Code) under the health 
     reimbursement arrangement with respect to the employee.
       (e) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2009.

             DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

     SEC. 1001. TABLE OF CONTENTS OF DIVISION.

       The table of contents of this division is as follows:

Sec. 1001. Table of contents of division.

                  TITLE I--IMPROVING HEALTH CARE VALUE

           Subtitle A--Provisions Related to Medicare Part A

                     Part 1--Market Basket Updates

Sec. 1101. Skilled nursing facility payment update.
Sec. 1102. Inpatient rehabilitation facility payment update.

[[Page 27256]]

Sec. 1103. Incorporating productivity improvements into market basket 
              updates that do not already incorporate such 
              improvements.

                Part 2--Other Medicare Part A Provisions

Sec. 1111. Payments to skilled nursing facilities.
Sec. 1112. Medicare DSH report and payment adjustments in response to 
              coverage expansion.
Sec. 1113. Extension of hospice regulation moratorium.
Sec. 1114. Permitting physician assistants to order post-hospital 
              extended care services and to provide for recognition of 
              attending physician assistants as attending physicians to 
              serve hospice patients.

                Subtitle B--Provisions Related to Part B

                      Part 1--Physicians' Services

Sec. 1121. Resource-based feedback program for physicians in Medicare.
Sec. 1122. Misvalued codes under the physician fee schedule.
Sec. 1123. Payments for efficient areas.
Sec. 1124. Modifications to the Physician Quality Reporting Initiative 
              (PQRI).
Sec. 1125. Adjustment to Medicare payment localities.

                     Part 2--Market Basket Updates

Sec. 1131. Incorporating productivity improvements into market basket 
              updates that do not already incorporate such 
              improvements.

                        Part 3--Other Provisions

Sec. 1141. Rental and purchase of power-driven wheelchairs.
Sec. 1141A. Election to take ownership, or to decline ownership, of a 
              certain item of complex durable medical equipment after 
              the 13-month capped rental period ends.
Sec. 1142. Extension of payment rule for brachytherapy.
Sec. 1143. Home infusion therapy report to Congress.
Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost 
              data and other data.
Sec. 1145. Treatment of certain cancer hospitals.
Sec. 1146. Payment for imaging services.
Sec. 1147. Durable medical equipment program improvements.
Sec. 1148. MedPAC study and report on bone mass measurement.
Sec. 1149. Timely access to post-mastectomy items.
Sec. 1149A. Payment for biosimilar biological products.
Sec. 1149B. Study and report on DME competitive bidding process.

        Subtitle C--Provisions Related to Medicare Parts A and B

Sec. 1151. Reducing potentially preventable hospital readmissions.
Sec. 1152. Post acute care services payment reform plan and bundling 
              pilot program.
Sec. 1153. Home health payment update for 2010.
Sec. 1154. Payment adjustments for home health care.
Sec. 1155. Incorporating productivity improvements into market basket 
              update for home health services.
Sec. 1155A. MedPAC study on variation in home health margins.
Sec. 1155B. Permitting home health agencies to assign the most 
              appropriate skilled service to make the initial 
              assessment visit under a Medicare home health plan of 
              care for rehabilitation cases.
Sec. 1156. Limitation on Medicare exceptions to the prohibition on 
              certain physician referrals made to hospitals.
Sec. 1157. Institute of Medicine study of geographic adjustment factors 
              under Medicare.
Sec. 1158. Revision of medicare payment systems to address geographic 
              inequities.
Sec. 1159. Institute of Medicine study of geographic variation in 
              health care spending and promoting high-value health 
              care.
Sec. 1160. Implementation, and Congressional review, of proposal to 
              revise Medicare payments to promote high value health 
              care.

                 Subtitle D--Medicare Advantage Reforms

                   Part 1--Payment and Administration

Sec. 1161. Phase-in of payment based on fee-for-service costs; quality 
              bonus payments.
Sec. 1162. Authority for Secretarial coding intensity adjustment 
              authority.
Sec. 1163. Simplification of annual beneficiary election periods.
Sec. 1164. Extension of reasonable cost contracts.
Sec. 1165. Limitation of waiver authority for employer group plans.
Sec. 1166. Improving risk adjustment for payments.
Sec. 1167. Elimination of MA Regional Plan Stabilization Fund.
Sec. 1168. Study regarding the effects of calculating Medicare 
              Advantage payment rates on a regional average of Medicare 
              fee for service rates.

             Part 2--Beneficiary Protections and Anti-Fraud

Sec. 1171. Limitation on cost-sharing for individual health services.
Sec. 1172. Continuous open enrollment for enrollees in plans with 
              enrollment suspension.
Sec. 1173. Information for beneficiaries on MA plan administrative 
              costs.
Sec. 1174. Strengthening audit authority.
Sec. 1175. Authority to deny plan bids.
Sec. 1175A. State authority to enforce standardized marketing 
              requirements.

                Part 3--Treatment of Special Needs Plans

Sec. 1176. Limitation on enrollment outside open enrollment period of 
              individuals into chronic care specialized MA plans for 
              special needs individuals.
Sec. 1177. Extension of authority of special needs plans to restrict 
              enrollment; service area moratorium for certain SNPs.
Sec. 1178. Extension of Medicare senior housing plans.

              Subtitle E--Improvements to Medicare Part D

Sec. 1181. Elimination of coverage gap.
Sec. 1182. Discounts for certain part D drugs in original coverage gap.
Sec. 1183. Repeal of provision relating to submission of claims by 
              pharmacies located in or contracting with long-term care 
              facilities.
Sec. 1184. Including costs incurred by AIDS drug assistance programs 
              and Indian Health Service in providing prescription drugs 
              toward the annual out-of-pocket threshold under part D.
Sec. 1185. No mid-year formulary changes permitted.
Sec. 1186. Negotiation of lower covered part D drug prices on behalf of 
              Medicare beneficiaries.
Sec. 1187. Accurate dispensing in long-term care facilities.
Sec. 1188. Free generic fill.
Sec. 1189. State certification prior to waiver of licensure 
              requirements under Medicare prescription drug program.

             Subtitle F--Medicare Rural Access Protections

Sec. 1191. Telehealth expansion and enhancements.
Sec. 1192. Extension of outpatient hold harmless provision.
Sec. 1193. Extension of section 508 hospital reclassifications.
Sec. 1194. Extension of geographic floor for work.
Sec. 1195. Extension of payment for technical component of certain 
              physician pathology services.
Sec. 1196. Extension of ambulance add-ons.

              TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

  Subtitle A--Improving and Simplifying Financial Assistance for Low 
                     Income Medicare Beneficiaries

Sec. 1201. Improving assets tests for Medicare Savings Program and low-
              income subsidy program.
Sec. 1202. Elimination of part D cost-sharing for certain non-
              institutionalized full-benefit dual eligible individuals.
Sec. 1203. Eliminating barriers to enrollment.
Sec. 1204. Enhanced oversight relating to reimbursements for 
              retroactive low income subsidy enrollment.
Sec. 1205. Intelligent assignment in enrollment.
Sec. 1206. Special enrollment period and automatic enrollment process 
              for certain subsidy eligible individuals.
Sec. 1207. Application of MA premiums prior to rebate and quality bonus 
              payments in calculation of low income subsidy benchmark.

                Subtitle B--Reducing Health Disparities

Sec. 1221. Ensuring effective communication in Medicare.
Sec. 1222. Demonstration to promote access for Medicare beneficiaries 
              with limited English proficiency by providing 
              reimbursement for culturally and linguistically 
              appropriate services.
Sec. 1223. IOM report on impact of language access services.
Sec. 1224. Definitions.

                 Subtitle C--Miscellaneous Improvements

Sec. 1231. Extension of therapy caps exceptions process.
Sec. 1232. Extended months of coverage of immunosuppressive drugs for 
              kidney transplant patients and other renal dialysis 
              provisions.
Sec. 1233. Voluntary advance care planning consultation.
Sec. 1234. Part B special enrollment period and waiver of limited 
              enrollment penalty for TRICARE beneficiaries.

[[Page 27257]]

Sec. 1235. Exception for use of more recent tax year in case of gains 
              from sale of primary residence in computing part B 
              income-related premium.
Sec. 1236. Demonstration program on use of patient decisions aids.

    TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND 
                            COORDINATED CARE

Sec. 1301. Accountable Care Organization pilot program.
Sec. 1302. Medical home pilot program.
Sec. 1303. Payment incentive for selected primary care services.
Sec. 1304. Increased reimbursement rate for certified nurse-midwives.
Sec. 1305. Coverage and waiver of cost-sharing for preventive services.
Sec. 1306. Waiver of deductible for colorectal cancer screening tests 
              regardless of coding, subsequent diagnosis, or ancillary 
              tissue removal.
Sec. 1307. Excluding clinical social worker services from coverage 
              under the medicare skilled nursing facility prospective 
              payment system and consolidated payment.
Sec. 1308. Coverage of marriage and family therapist services and 
              mental health counselor services.
Sec. 1309. Extension of physician fee schedule mental health add-on.
Sec. 1310. Expanding access to vaccines.
Sec. 1311. Expansion of Medicare-Covered Preventive Services at 
              Federally Qualified Health Centers.
Sec. 1312. Independence at home demonstration program.
Sec. 1313. Recognition of certified diabetes educators as certified 
              providers for purposes of Medicare diabetes outpatient 
              self-management training services.

                           TITLE IV--QUALITY

             Subtitle A--Comparative Effectiveness Research

Sec. 1401. Comparative effectiveness research.

                 Subtitle B--Nursing Home Transparency

   Part 1--Improving Transparency of Information on Skilled Nursing 
  Facilities, Nursing Facilities, and Other Long-term Care Facilities

Sec. 1411. Required disclosure of ownership and additional disclosable 
              parties information.
Sec. 1412. Accountability requirements.
Sec. 1413. Nursing home compare Medicare website.
Sec. 1414. Reporting of expenditures.
Sec. 1415. Standardized complaint form.
Sec. 1416. Ensuring staffing accountability.
Sec. 1417. Nationwide program for national and State background checks 
              on direct patient access employees of long-term care 
              facilities and providers.

                     Part 2--Targeting Enforcement

Sec. 1421. Civil money penalties.
Sec. 1422. National independent monitor pilot program.
Sec. 1423. Notification of facility closure.

                    Part 3--Improving Staff Training

Sec. 1431. Dementia and abuse prevention training.
Sec. 1432. Study and report on training required for certified nurse 
              aides and supervisory staff.
Sec. 1433. Qualification of director of food services of a skilled 
              nursing facility or nursing facility.

                    Subtitle C--Quality Measurements

Sec. 1441. Establishment of national priorities for quality 
              improvement.
Sec. 1442. Development of new quality measures; GAO evaluation of data 
              collection process for quality measurement.
Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of 
              quality measures.
Sec. 1444. Application of quality measures.
Sec. 1445. Consensus-based entity funding.
Sec. 1446. Quality Indicators for care of people with Alzheimers 
              disease.

           Subtitle D--Physician Payments Sunshine Provision

Sec. 1451. Reports on financial relationships between manufacturers and 
              distributors of covered drugs, devices, biologicals, or 
              medical supplies under Medicare, Medicaid, or CHIP and 
              physicians and other health care entities and between 
              physicians and other health care entities.

   Subtitle E--Public Reporting on Health Care-Associated Infections

Sec. 1461. Requirement for public reporting by hospitals and ambulatory 
              surgical centers on health care-associated infections.

              TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

Sec. 1501. Distribution of unused residency positions.
Sec. 1502. Increasing training in nonprovider settings.
Sec. 1503. Rules for counting resident time for didactic and scholarly 
              activities and other activities.
Sec. 1504. Preservation of resident cap positions from closed 
              hospitals.
Sec. 1505. Improving accountability for approved medical residency 
              training.

                      TITLE VI--PROGRAM INTEGRITY

     Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse

Sec. 1601. Increased funding and flexibility to fight fraud and abuse.

           Subtitle B--Enhanced Penalties for Fraud and Abuse

Sec. 1611. Enhanced penalties for false statements on provider or 
              supplier enrollment applications.
Sec. 1612. Enhanced penalties for submission of false statements 
              material to a false claim.
Sec. 1613. Enhanced penalties for delaying inspections.
Sec. 1614. Enhanced hospice program safeguards.
Sec. 1615. Enhanced penalties for individuals excluded from program 
              participation.
Sec. 1616. Enhanced penalties for provision of false information by 
              Medicare Advantage and part D plans.
Sec. 1617. Enhanced penalties for Medicare Advantage and part D 
              marketing violations.
Sec. 1618. Enhanced penalties for obstruction of program audits.
Sec. 1619. Exclusion of certain individuals and entities from 
              participation in Medicare and State health care programs.
Sec. 1620.  OIG authority to exclude from Federal health care programs 
              officers and owners of entities convicted of fraud.
Sec. 1621. Self-referral disclosure protocol.

         Subtitle C--Enhanced Program and Provider Protections

Sec. 1631. Enhanced CMS program protection authority.
Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure 
              requirements relating to previous affiliations.
Sec. 1633. Required inclusion of payment modifier for certain 
              evaluation and management services.
Sec. 1634. Evaluations and reports required under Medicare Integrity 
              Program.
Sec. 1635. Require providers and suppliers to adopt programs to reduce 
              waste, fraud, and abuse.
Sec. 1636. Maximum period for submission of Medicare claims reduced to 
              not more than 12 months.
Sec. 1637. Physicians who order durable medical equipment or home 
              health services required to be Medicare enrolled 
              physicians or eligible professionals.
Sec. 1638. Requirement for physicians to provide documentation on 
              referrals to programs at high risk of waste and abuse.
Sec. 1639. Face-to-face encounter with patient required before 
              eligibility certifications for home health services or 
              durable medical equipment.
Sec. 1640. Extension of testimonial subpoena authority to program 
              exclusion investigations.
Sec. 1641. Required repayments of Medicare and Medicaid overpayments.
Sec. 1642. Expanded application of hardship waivers for OIG exclusions 
              to beneficiaries of any Federal health care program.
Sec. 1643. Access to certain information on renal dialysis facilities.
Sec. 1644. Billing agents, clearinghouses, or other alternate payees 
              required to register under Medicare.
Sec. 1645. Conforming civil monetary penalties to False Claims Act 
              amendments.
Sec. 1646. Requiring provider and supplier payments under Medicare to 
              be made through direct deposit or electronic funds 
              transfer (EFT) at insured depository institutions.
Sec. 1647. Inspector General for the Health Choices Administration.

 Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and 
                                 Abuse

Sec. 1651. Access to Information Necessary to Identify Fraud, Waste, 
              and Abuse.
Sec. 1652. Elimination of duplication between the Healthcare Integrity 
              and Protection Data Bank and the National Practitioner 
              Data Bank.
Sec. 1653. Compliance with HIPAA privacy and security standards.
Sec. 1654. Disclosure of Medicare Fraud and Abuse Hotline Number on 
              Explanation of Benefits.

                      TITLE VII--MEDICAID AND CHIP

                 Subtitle A--Medicaid and Health Reform

Sec. 1701. Eligibility for individuals with income below 150 percent of 
              the Federal poverty level.
Sec. 1702.  Requirements and special rules for certain Medicaid 
              eligible individuals.
Sec. 1703. CHIP and Medicaid maintenance of eligibility.

[[Page 27258]]

Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.

                         Subtitle B--Prevention

Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.

                           Subtitle C--Access

Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for 
              children program.
Sec. 1726. Requiring coverage of services of podiatrists.
Sec. 1726A. Requiring coverage of services of optometrists.
Sec. 1727. Therapeutic foster care.
Sec. 1728. Assuring adequate payment levels for services.
Sec. 1729. Preserving Medicaid coverage for youths upon release from 
              public institutions.
Sec. 1730. Quality measures for maternity and adult health services 
              under Medicaid and CHIP.
Sec. 1730A. Accountable care organization pilot program.
Sec. 1730B. FQHC coverage.

                          Subtitle D--Coverage

Sec. 1731. Optional Medicaid coverage of low-income HIV-infected 
              individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain 
              CHIP programs.
Sec. 1734. Preventing the application under CHIP of coverage waiting 
              periods for certain children.
Sec. 1735. Adult day health care services.
Sec. 1736. Medicaid coverage for citizens of Freely Associated States.
Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency 
              transportation to medically necessary services.
Sec. 1738. State option to disregard certain income in providing 
              continued Medicaid coverage for certain individuals with 
              extremely high prescription costs.
Sec. 1739. Provisions relating to community living assistance services 
              and supports (CLASS).
Sec. 1739A. Sense of Congress regarding Community First Choice Option 
              to provide Medicaid Coverage of Community-Based Attendant 
              Services and Supports.

                         Subtitle E--Financing

Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of 
              Medicaid managed care organizations.
Sec. 1744. Payments for graduate medical education.
Sec. 1745. Nursing Facility Supplemental Payment Program.
Sec. 1746. Report on Medicaid payments.
Sec. 1747. Reviews of Medicaid.
Sec. 1748. Extension of delay in managed care organization provider tax 
              elimination.
Sec. 1749. Extension of ARRA increase in FMAP.

                  Subtitle F--Waste, Fraud, and Abuse

Sec. 1751. Health care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity 
              Program.
Sec. 1753. Require providers and suppliers to adopt programs to reduce 
              waste, fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed care organizations.
Sec. 1756. Termination of provider participation under Medicaid and 
              CHIP if terminated under Medicare or other State plan or 
              child health plan.
Sec. 1757. Medicaid and CHIP exclusion from participation relating to 
              certain ownership, control, and management affiliations.
Sec. 1758. Requirement to report expanded set of data elements under 
              MMIS to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees 
              required to register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Sec. 1761. Mandatory State use of national correct coding initiative.

                Subtitle G--Payments to the Territories

Sec. 1771. Payment to territories.

                       Subtitle H--Miscellaneous

Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
Sec. 1783. Assuring transparency of information.
Sec. 1784. Medicaid and CHIP Payment and Access Commission.
Sec. 1785. Outreach and enrollment of Medicaid and CHIP eligible 
              individuals.
Sec. 1786. Prohibitions on Federal Medicaid and CHIP payment for 
              undocumented aliens.
Sec. 1787. Demonstration project for stabilization of emergency medical 
              conditions by institutions for mental diseases.
Sec. 1788. Application of Medicaid Improvement Fund.
Sec. 1789. Treatment of certain Medicaid brokers.
Sec. 1790. Rule for changes requiring State legislation.

                 TITLE VIII--REVENUE-RELATED PROVISIONS

Sec. 1801. Disclosures to facilitate identification of individuals 
              likely to be ineligible for the low-income assistance 
              under the Medicare prescription drug program to assist 
              Social Security Administration's outreach to eligible 
              individuals.
Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for 
              Trust Fund.

                   TITLE IX--MISCELLANEOUS PROVISIONS

Sec. 1901. Repeal of trigger provision.
Sec. 1902. Repeal of comparative cost adjustment (CCA) program.
Sec. 1903. Extension of gainsharing demonstration.
Sec. 1904. Grants to States for quality home visitation programs for 
              families with young children and families expecting 
              children.
Sec. 1905. Improved coordination and protection for dual eligibles.
Sec. 1906. Assessment of medicare cost-intensive diseases and 
              conditions.
Sec. 1907. Establishment of Center for Medicare and Medicaid Innovation 
              within CMS.
Sec. 1908. Application of emergency services laws.
Sec. 1909. Disregard under the Supplemental Security Income program of 
              compensation for participation in clinical trials for 
              rare diseases or conditions.

                  TITLE I--IMPROVING HEALTH CARE VALUE

           Subtitle A--Provisions Related to Medicare Part A

                     PART 1--MARKET BASKET UPDATES

     SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.

       (a) In General.--Section 1888(e)(4)(E)(ii) of the Social 
     Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
       (1) in subclause (III), by striking ``and'' at the end;
       (2) by redesignating subclause (IV) as subclause (VI); and
       (3) by inserting after subclause (III) the following new 
     subclauses:

       ``(IV) for each of fiscal years 2004 through 2009, the rate 
     computed for the previous fiscal year increased by the 
     skilled nursing facility market basket percentage change for 
     the fiscal year involved;
       ``(V) for fiscal year 2010, the rate computed for the 
     previous fiscal year; and''.

       (b) Delayed Effective Date.--Section 1888(e)(4)(E)(ii)(V) 
     of the Social Security Act, as inserted by subsection (a)(3), 
     shall not apply to payment for days before January 1, 2010.

     SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.

       (a) In General.--Section 1886(j)(3)(C) of the Social 
     Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by 
     striking ``and 2009'' and inserting ``through 2010''.
       (b) Delayed Effective Date.--The amendment made by 
     subsection (a) shall not apply to payment units occurring 
     before January 1, 2010.

     SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO 
                   MARKET BASKET UPDATES THAT DO NOT ALREADY 
                   INCORPORATE SUCH IMPROVEMENTS.

       (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of 
     the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is 
     amended--
       (1) in clause (iii)--
       (A) by striking ``(iii) For purposes of this 
     subparagraph,'' and inserting ``(iii)(I) For purposes of this 
     subparagraph, subject to the productivity adjustment 
     described in subclause (II),''; and
       (B) by adding at the end the following new subclause:
       ``(II) The productivity adjustment described in this 
     subclause, with respect to an increase or change for a fiscal 
     year or year or cost reporting period, or other annual 
     period, is a productivity offset in the form of a reduction 
     in such increase or change equal to the percentage change in 
     the 10-year moving average of annual economy-wide private 
     nonfarm business multi-factor productivity (as recently 
     published in final form before the promulgation or 
     publication of such increase for the year or period 
     involved). Except as otherwise provided, any reference to the 
     increase described in this clause shall be a reference to the 
     percentage increase described in subclause (I) minus the 
     percentage change under this subclause.'';

[[Page 27259]]

       (2) in the first sentence of clause (viii)(I), by inserting 
     ``(but not below zero)'' after ``shall be reduced''; and
       (3) in the first sentence of clause (ix)(I)--
       (A) by inserting ``(determined without regard to clause 
     (iii)(II))'' after ``clause (i)'' the second time it appears; 
     and
       (B) by inserting ``(but not below zero)'' after 
     ``reduced''.
       (b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of 
     such Act (42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting 
     ``subject to the productivity adjustment described in section 
     1886(b)(3)(B)(iii)(II)'' after ``as calculated by the 
     Secretary''.
       (c) Long Term Care Hospitals.--Section 1886(m) of the 
     Social Security Act (42 U.S.C. 1395ww(m)) is amended by 
     adding at the end the following new paragraph:
       ``(3) Productivity adjustment.--In implementing the system 
     described in paragraph (1) for discharges occurring on or 
     after January 1, 2010, during the rate year ending in 2010 or 
     any subsequent rate year for a hospital, to the extent that 
     an annual percentage increase factor applies to a standard 
     Federal rate for such discharges for the hospital, such 
     factor shall be subject to the productivity adjustment 
     described in subsection (b)(3)(B)(iii)(II).''.
       (d) Inpatient Rehabilitation Facilities.--The second 
     sentence of section 1886(j)(3)(C) of the Social Security Act 
     (42 U.S.C. 1395ww(j)(3)(C)) is amended by inserting 
     ``(subject to the productivity adjustment described in 
     subsection (b)(3)(B)(iii)(II))'' after ``appropriate 
     percentage increase''.
       (e) Psychiatric Hospitals.--Section 1886 of the Social 
     Security Act (42 U.S.C. 1395ww) is amended by adding at the 
     end the following new subsection:
       ``(o) Prospective Payment for Psychiatric Hospitals.--
       ``(1) Reference to establishment and implementation of 
     system.--For provisions related to the establishment and 
     implementation of a prospective payment system for payments 
     under this title for inpatient hospital services furnished by 
     psychiatric hospitals (as described in clause (i) of 
     subsection (d)(1)(B) and psychiatric units (as described in 
     the matter following clause (v) of such subsection), see 
     section 124 of the Medicare, Medicaid, and SCHIP Balanced 
     Budget Refinement Act of 1999.
       ``(2) Productivity adjustment.--In implementing the system 
     described in paragraph (1) for days occurring during the rate 
     year ending in 2011 or any subsequent rate year for a 
     psychiatric hospital or unit described in such paragraph, to 
     the extent that an annual percentage increase factor applies 
     to a base rate for such days for the hospital or unit, 
     respectively, such factor shall be subject to the 
     productivity adjustment described in subsection 
     (b)(3)(B)(iii)(II).''.
       (f) Hospice Care.--Subclause (VII) of section 
     1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C. 
     1395f(i)(1)(C)(ii)) is amended by inserting after ``the 
     market basket percentage increase'' the following: ``(which 
     is subject to the productivity adjustment described in 
     section 1886(b)(3)(B)(iii)(II))''.
       (g) Effective Dates.--
       (1) IPPS.--The amendments made by subsection (a) shall 
     apply to annual increases effected for fiscal years beginning 
     with fiscal year 2010, but only with respect to discharges 
     occurring on or after January 1, 2010.
       (2) SNF and irf.--The amendments made by subsections (b) 
     and (d) shall apply to annual increases effected for fiscal 
     years beginning with fiscal year 2011.
       (3) Hospice care.--The amendment made by subsection (f) 
     shall apply to annual increases effected for fiscal years 
     beginning with fiscal year 2010, but only with respect to 
     days of care occurring on or after January 1, 2010.

                PART 2--OTHER MEDICARE PART A PROVISIONS

     SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.

       (a) Change in Recalibration Factor.--
       (1) Analysis.--The Secretary of Health and Human Services 
     shall conduct, using calendar year 2006 claims data, an 
     initial analysis comparing total payments under title XVIII 
     of the Social Security Act for skilled nursing facility 
     services under the RUG-53 and under the RUG-44 classification 
     systems.
       (2) Adjustment in recalibration factor.--Based on the 
     initial analysis under paragraph (1), the Secretary shall 
     adjust the case mix indexes under section 1888(e)(4)(G)(i) of 
     the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for 
     fiscal year 2010 by the appropriate recalibration factor as 
     proposed in the final rule for Medicare skilled nursing 
     facilities issued by such Secretary on August 11, 2009 (74 
     Federal Register 40287 et seq.).
       (b) Change in Payment for Nontherapy Ancillary (NTA) 
     Services and Therapy Services.--
       (1) Changes under current snf classification system.--
       (A) In general.--Subject to subparagraph (B), the Secretary 
     of Health and Human Services shall, under the system for 
     payment of skilled nursing facility services under section 
     1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)), 
     increase payment by 10 percent for non-therapy ancillary 
     services (as specified by the Secretary in the notice issued 
     on November 27, 1998 (63 Federal Register 65561 et seq.)) and 
     shall decrease payment for the therapy case mix component of 
     such rates by 5.5 percent.
       (B) Effective date.--The changes in payment described in 
     subparagraph (A) shall apply for days on or after April 1, 
     2010, and until the Secretary implements an alternative case 
     mix classification system for payment of skilled nursing 
     facility services under section 1888(e) of the Social 
     Security Act (42 U.S.C. 1395yy(e)).
       (C) Implementation.--Notwithstanding any other provision of 
     law, the Secretary may implement by program instruction or 
     otherwise the provisions of this paragraph.
       (2) Changes under a future snf case mix classification 
     system.--
       (A) Analysis.--
       (i) In general.--The Secretary of Health and Human Services 
     shall analyze payments for non-therapy ancillary services 
     under a future skilled nursing facility classification system 
     to ensure the accuracy of payment for non-therapy ancillary 
     services. Such analysis shall consider use of appropriate 
     predictors which may include age, physical and mental status, 
     ability to perform activities of daily living, prior nursing 
     home stay, diagnoses, broad RUG category, and a proxy for 
     length of stay.
       (ii) Application.--Such analysis shall be conducted in a 
     manner such that the future skilled nursing facility 
     classification system is implemented to apply to services 
     furnished during a fiscal year beginning with fiscal year 
     2011.
       (B) Consultation.--In conducting the analysis under 
     subparagraph (A), the Secretary shall consult with interested 
     parties, including the Medicare Payment Advisory Commission 
     and other interested stakeholders, to identify appropriate 
     predictors of nontherapy ancillary costs.
       (C) Rulemaking.--The Secretary shall include the result of 
     the analysis under subparagraph (A) in the fiscal year 2011 
     rulemaking cycle for purposes of implementation beginning for 
     such fiscal year.
       (D) Implementation.--Subject to subparagraph (E) and 
     consistent with subparagraph (A)(ii), the Secretary shall 
     implement changes to payments for non-therapy ancillary 
     services (which shall include a separate rate component for 
     non-therapy ancillary services and may include use of a model 
     that predicts payment amounts applicable for non-therapy 
     ancillary services) under such future skilled nursing 
     facility services classification system as the Secretary 
     determines appropriate based on the analysis conducted 
     pursuant to subparagraph (A).
       (E) Budget neutrality.--The Secretary shall implement 
     changes described in subparagraph (D) in a manner such that 
     the estimated expenditures under such future skilled nursing 
     facility services classification system for a fiscal year 
     beginning with fiscal year 2011 with such changes would be 
     equal to the estimated expenditures that would otherwise 
     occur under title XVIII of the Social Security Act under such 
     future skilled nursing facility services classification 
     system for such year without such changes.
       (c) Outlier Policy for NTA and Therapy.--Section 1888(e) of 
     the Social Security Act (42 U.S.C. 1395yy(e)) is amended by 
     adding at the end the following new paragraph:
       ``(13) Outliers for nta and therapy.--
       ``(A) In general.--With respect to outliers because of 
     unusual variations in the type or amount of medically 
     necessary care, beginning with October 1, 2010, the 
     Secretary--
       ``(i) shall provide for an addition or adjustment to the 
     payment amount otherwise made under this section with respect 
     to non-therapy ancillary services in the case of such 
     outliers; and
       ``(ii) may provide for such an addition or adjustment to 
     the payment amount otherwise made under this section with 
     respect to therapy services in the case of such outliers.
       ``(B) Outliers based on aggregate costs.--Outlier 
     adjustments or additional payments described in subparagraph 
     (A) shall be based on aggregate costs during a stay in a 
     skilled nursing facility and not on the number of days in 
     such stay.
       ``(C) Budget neutrality.--The Secretary shall reduce 
     estimated payments that would otherwise be made under the 
     prospective payment system under this subsection with respect 
     to a fiscal year by 2 percent. The total amount of the 
     additional payments or payment adjustments for outliers made 
     under this paragraph with respect to a fiscal year may not 
     exceed 2 percent of the total payments projected or estimated 
     to be made based on the prospective payment system under this 
     subsection for the fiscal year.''.
       (d) Conforming Amendments.--Section 1888(e)(8) of such Act 
     (42 U.S.C. 1395yy(e)(8)) is amended--
       (1) in subparagraph (A)--
       (A) by striking ``and'' before ``adjustments''; and
       (B) by inserting ``, and adjustment under section 1111(b) 
     of the Affordable Health Care for America Act'' before the 
     semicolon at the end;
       (2) in subparagraph (B), by striking ``and'';
       (3) in subparagraph (C), by striking the period and 
     inserting ``; and''; and
       (4) by adding at the end the following new subparagraph:
       ``(D) the establishment of outliers under paragraph 
     (13).''.

[[Page 27260]]



     SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN 
                   RESPONSE TO COVERAGE EXPANSION.

       (a) DSH Report.--
       (1) In general.--Not later than January 1, 2016, the 
     Secretary of Health and Human Services shall submit to 
     Congress a report on Medicare DSH taking into account the 
     impact of the health care reforms carried out under division 
     A in reducing the number of uninsured individuals. The report 
     shall include recommendations relating to the following:
       (A) The appropriate amount, targeting, and distribution of 
     Medicare DSH to compensate for higher Medicare costs 
     associated with serving low-income beneficiaries (taking into 
     account variations in the empirical justification for 
     Medicare DSH attributable to hospital characteristics, 
     including bed size), consistent with the original intent of 
     Medicare DSH.
       (B) The appropriate amount, targeting, and distribution of 
     Medicare DSH to hospitals given their continued uncompensated 
     care costs, to the extent such costs remain.
       (2) Coordination with medicaid dsh report.--The Secretary 
     shall coordinate the report under this subsection with the 
     report on Medicaid DSH under section 1704(a).
       (b) Payment Adjustments in Response to Coverage 
     Expansion.--
       (1) In general.--If there is a significant decrease in the 
     national rate of uninsurance as a result of this Act (as 
     determined under paragraph (2)(A)), then the Secretary of 
     Health and Human Services shall, beginning in fiscal year 
     2017, implement the following adjustments to Medicare DSH:
       (A) In lieu of the amount of Medicare DSH payment that 
     would otherwise be made under section 1886(d)(5)(F) of the 
     Social Security Act, the amount of Medicare DSH payment shall 
     be an amount based on the recommendations of the report under 
     subsection (a)(1)(A) and shall take into account variations 
     in the empirical justification for Medicare DSH attributable 
     to hospital characteristics, including bed size.
       (B) Subject to paragraph (3), make an additional payment to 
     a hospital by an amount that is estimated based on the amount 
     of uncompensated care provided by the hospital based on 
     criteria for uncompensated care as determined by the 
     Secretary, which shall exclude bad debt.
       (2) Significant decrease in national rate of uninsurance as 
     a result of this act.--For purposes of this subsection--
       (A) In general.--There is a ``significant decrease in the 
     national rate of uninsurance as a result of this Act'' if 
     there is a decrease in the national rate of uninsurance (as 
     defined in subparagraph (B)) from 2012 to 2014 that exceeds 8 
     percentage points.
       (B) National rate of uninsurance defined.--The term 
     ``national rate of uninsurance'' means, for a year, such rate 
     for the under-65 population for the year as determined and 
     published by the Bureau of the Census in its Current 
     Population Survey in or about September of the succeeding 
     year.
       (3) Uncompensated care increase.--
       (A) Computation of dsh savings.--For each fiscal year 
     (beginning with fiscal year 2017), the Secretary shall 
     estimate the aggregate reduction in the amount of Medicare 
     DSH payment that would be expected to result from the 
     adjustment under paragraph (1)(A).
       (B) Structure of payment increase.--The Secretary shall 
     compute the additional payment to a hospital as described in 
     paragraph (1)(B) for a fiscal year in accordance with a 
     formula established by the Secretary that provides that--
       (i) the estimated aggregate amount of such increase for the 
     fiscal year does not exceed 50 percent of the aggregate 
     reduction in Medicare DSH estimated by the Secretary for such 
     fiscal year; and
       (ii) hospitals with higher levels of uncompensated care 
     receive a greater increase.
       (c) Medicare DSH.--In this section, the term ``Medicare 
     DSH'' means adjustments in payments under section 
     1886(d)(5)(F) of the Social Security Act (42 U.S.C. 
     1395ww(d)(5)(F)) for inpatient hospital services furnished by 
     disproportionate share hospitals.

     SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATORIUM.

       Section 4301(a) of division B of the American Recovery and 
     Reinvestment Act of 2009 (Public Law 111-5) is amended--
       (1) by striking ``October 1, 2009'' and inserting ``October 
     1, 2010''; and
       (2) by striking ``for fiscal year 2009'' and inserting 
     ``for fiscal years 2009 and 2010''.

     SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-
                   HOSPITAL EXTENDED CARE SERVICES AND TO PROVIDE 
                   FOR RECOGNITION OF ATTENDING PHYSICIAN 
                   ASSISTANTS AS ATTENDING PHYSICIANS TO SERVE 
                   HOSPICE PATIENTS.

       (a) Ordering Post-hospital Extended Care Services.--Section 
     1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is 
     amended--
       (1) in paragraph (2) in the matter preceding subparagraph 
     (A), is amended by striking ``nurse practitioner or clinical 
     nurse specialist'' and inserting ``nurse practitioner, a 
     clinical nurse specialist, or a physician assistant''.
       (2) in the second sentence, by striking ``or clinical nurse 
     specialist'' and inserting ``clinical nurse specialist, or 
     physician assistant''.
       (b) Recognition of Attending Physician Assistants as 
     Attending Physicians to Serve Hospice Patients.--
       (1) In general.--Section 1861(dd)(3)(B) of such Act (42 
     U.S.C. 1395x(dd)(3)(B)) is amended--
       (A) by striking ``or nurse'' and inserting ``, the nurse''; 
     and
       (B) by inserting ``or the physician assistant (as defined 
     in such subsection),'' after ``subsection (aa)(5)),''.
       (2) Conforming amendment.--Section 1814(a)(7)(A)(i)(I) of 
     such Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by 
     inserting ``or a physician assistant'' after ``a nurse 
     practitioner''.
       (3) Construction.--Nothing in the amendments made by this 
     subsection shall be construed as changing the requirements of 
     section 1842(b)(6)(C) of the Social Security Act (42 U.S.C. 
     1395u(b)(6)(C)) with respect to payment for services of 
     physician assistants under part B of title XVIII of such Act.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2010.

                Subtitle B--Provisions Related to Part B

                      PART 1--PHYSICIANS' SERVICES

     SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR PHYSICIANS IN 
                   MEDICARE.

       Section 1848(n) of the Social Security Act (42 U.S.C. 
     1395w-4(n)) is amended by adding at the end the following new 
     paragraph:
       ``(9) Feedback implementation plan.--
       ``(A) Timeline for feedback program.--
       ``(i) Evaluation.--During 2011 the Secretary shall conduct 
     the evaluation specified in subparagraph (E)(i).
       ``(ii) Expansion.--The Secretary shall expand the Program 
     under this subsection as specified in subparagraph (E)(ii).
       ``(B) Establishment of nature of reports.--
       ``(i) In general.--The Secretary shall develop and specify 
     the nature of the reports that will be disseminated under 
     this subsection, based on results and findings from the 
     Program under this subsection as in existence before the date 
     of the enactment of this paragraph. Such reports may be based 
     on a per capita basis, an episode basis that combines 
     separate but clinically related physicians' services and 
     other items and services furnished or ordered by a physician 
     into an episode of care, as appropriate, or both.
       ``(ii) Timeline for development.--The nature of the reports 
     described in clause (i) shall be developed by not later than 
     January 1, 2012.
       ``(iii) Public availability.--The Secretary shall make the 
     details of the nature of the reports developed under clause 
     (i) available to the public.
       ``(C) Analysis of data.--The Secretary shall, for purposes 
     of preparing reports under this subsection, establish 
     methodologies as appropriate such as to--
       ``(i) attribute items and services, in whole or in part, to 
     physicians;
       ``(ii) identify appropriate physicians for purposes of 
     comparison under subparagraph (B)(i); and
       ``(iii) aggregate items and services attributed to a 
     physician under clause (i) into a composite measure per 
     individual.
       ``(D) Feedback program.--The Secretary shall engage in 
     efforts to disseminate reports under this subsection. In 
     disseminating such reports, the Secretary shall consider the 
     following:
       ``(i) Direct meetings between contracted physicians, 
     facilitated by the Secretary, to discuss the contents of 
     reports under this subsection, including any reasons for 
     divergence from local or national averages.
       ``(ii) Contract with local, non-profit entities engaged in 
     quality improvement efforts at the community level. Such 
     entities shall use the reports under this subsection, or such 
     equivalent tool as specified by the Secretary. Any exchange 
     of data under this paragraph shall be protected by 
     appropriate privacy safeguards.
       ``(iii) Mailings or other methods of communication that 
     facilitate large-scale dissemination.
       ``(iv) Other methods specified by the Secretary.
       ``(E) Evaluation and expansion.--
       ``(i) Evaluation.--The Secretary shall evaluate the methods 
     specified in subparagraph (D) with regard to their efficacy 
     in changing practice patterns to improve quality and decrease 
     costs.
       ``(ii) Expansion.--Taking into account the cost of each 
     method specified in subparagraph (D), the Secretary shall 
     develop a plan to disseminate reports under this subsection 
     in a significant manner in the regions and cities of the 
     country with the highest utilization of services under this 
     title. To the extent practicable, reports under this 
     subsection shall be disseminated to increasing numbers of 
     physicians each year, such that during 2014 and subsequent 
     years, reports are disseminated at least to physicians with 
     utilization rates among the highest 5 percent of the nation, 
     subject the authority to focus under paragraph (4).
       ``(F) Administration.--
       ``(i) Chapter 35 of title 44, United States Code shall not 
     apply to this paragraph.

[[Page 27261]]

       ``(ii) Notwithstanding any other provision of law, the 
     Secretary may implement the provisions of this paragraph by 
     program instruction or otherwise.''.

     SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

       (a) In General.--Section 1848(c)(2) of the Social Security 
     Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end 
     the following new subparagraphs:
       ``(K) Potentially misvalued codes.--
       ``(i) In general.--The Secretary shall--

       ``(I) periodically identify services as being potentially 
     misvalued using criteria specified in clause (ii); and
       ``(II) review and make appropriate adjustments to the 
     relative values established under this paragraph for services 
     identified as being potentially misvalued under subclause 
     (I).

       ``(ii) Identification of potentially misvalued codes.--For 
     purposes of identifying potentially misvalued services 
     pursuant to clause (i)(I), the Secretary shall examine (as 
     the Secretary determines to be appropriate) codes (and 
     families of codes as appropriate) for which there has been 
     the fastest growth; codes (and families of codes as 
     appropriate) that have experienced substantial changes in 
     practice expenses; codes for new technologies or services 
     within an appropriate period (such as three years) after the 
     relative values are initially established for such codes; 
     multiple codes that are frequently billed in conjunction with 
     furnishing a single service; codes with low relative values, 
     particularly those that are often billed multiple times for a 
     single treatment; codes which have not been subject to review 
     since the implementation of the RBRVS (the so-called 
     `Harvard-valued codes'); and such other codes determined to 
     be appropriate by the Secretary.
       ``(iii) Review and adjustments.--

       ``(I) The Secretary may use existing processes to receive 
     recommendations on the review and appropriate adjustment of 
     potentially misvalued services described clause (i)(II).
       ``(II) The Secretary may conduct surveys, other data 
     collection activities, studies, or other analyses as the 
     Secretary determines to be appropriate to facilitate the 
     review and appropriate adjustment described in clause 
     (i)(II).
       ``(III) The Secretary may use analytic contractors to 
     identify and analyze services identified under clause (i)(I), 
     conduct surveys or collect data, and make recommendations on 
     the review and appropriate adjustment of services described 
     in clause (i)(II).
       ``(IV) The Secretary may coordinate the review and 
     appropriate adjustment described in clause (i)(II) with the 
     periodic review described in subparagraph (B).
       ``(V) As part of the review and adjustment described in 
     clause (i)(II), including with respect to codes with low 
     relative values described in clause (ii), the Secretary may 
     make appropriate coding revisions (including using existing 
     processes for consideration of coding changes) which may 
     include consolidation of individual services into bundled 
     codes for payment under the fee schedule under subsection 
     (b).
       ``(VI) The provisions of subparagraph (B)(ii)(II) shall 
     apply to adjustments to relative value units made pursuant to 
     this subparagraph in the same manner as such provisions apply 
     to adjustments under subparagraph (B)(ii)(II).

       ``(L) Validating relative value units.--
       ``(i) In general.--The Secretary shall establish a process 
     to validate relative value units under the fee schedule under 
     subsection (b).
       ``(ii) Components and elements of work.--The process 
     described in clause (i) may include validation of work 
     elements (such as time, mental effort and professional 
     judgment, technical skill and physical effort, and stress due 
     to risk) involved with furnishing a service and may include 
     validation of the pre, post, and intra-service components of 
     work.
       ``(iii) Scope of codes.--The validation of work relative 
     value units shall include a sampling of codes for services 
     that is the same as the codes listed under subparagraph 
     (K)(ii)
       ``(iv) Methods.--The Secretary may conduct the validation 
     under this subparagraph using methods described in subclauses 
     (I) through (V) of subparagraph (K)(iii) as the Secretary 
     determines to be appropriate.
       ``(v) Adjustments.--The Secretary shall make appropriate 
     adjustments to the work relative value units under the fee 
     schedule under subsection (b). The provisions of subparagraph 
     (B)(ii)(II) shall apply to adjustments to relative value 
     units made pursuant to this subparagraph in the same manner 
     as such provisions apply to adjustments under subparagraph 
     (B)(ii)(II).''.
       (b) Implementation.--
       (1) Funding.--For purposes of carrying out the provisions 
     of subparagraphs (K) and (L) of 1848(c)(2) of the Social 
     Security Act, as added by subsection (a), in addition to 
     funds otherwise available, out of any funds in the Treasury 
     not otherwise appropriated, there are appropriated to the 
     Secretary of Health and Human Services for the Center for 
     Medicare & Medicaid Services Program Management Account 
     $20,000,000 for fiscal year 2010 and each subsequent fiscal 
     year. Amounts appropriated under this paragraph for a fiscal 
     year shall be available until expended.
       (2) Administration.--
       (A) Chapter 35 of title 44, United States Code and the 
     provisions of the Federal Advisory Committee Act (5 U.S.C. 
     App.) shall not apply to this section or the amendment made 
     by this section.
       (B) Notwithstanding any other provision of law, the 
     Secretary may implement subparagraphs (K) and (L) of 
     1848(c)(2) of the Social Security Act, as added by subsection 
     (a), by program instruction or otherwise.
       (C) Section 4505(d) of the Balanced Budget Act of 1997 is 
     repealed.
       (D) Except for provisions related to confidentiality of 
     information, the provisions of the Federal Acquisition 
     Regulation shall not apply to this section or the amendment 
     made by this section.
       (3) Focusing cms resources on potentially overvalued 
     codes.--Section 1868(a) of the Social Security Act (42 
     1395ee(a)) is repealed.

     SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

       Section 1833 of the Social Security Act (42 U.S.C. 1395l) 
     is amended by adding at the end the following new subsection:
       ``(x) Incentive Payments for Efficient Areas.--
       ``(1) In general.--In the case of services furnished under 
     the physician fee schedule under section 1848 on or after 
     January 1, 2011, and before January 1, 2013, by a supplier 
     that is paid under such fee schedule in an efficient area (as 
     identified under paragraph (2)), in addition to the amount of 
     payment that would otherwise be made for such services under 
     this part, there also shall be paid (on a monthly or 
     quarterly basis) an amount equal to 5 percent of the payment 
     amount for the services under this part.
       ``(2) Identification of efficient areas.--
       ``(A) In general.--Based upon available data, the Secretary 
     shall identify those counties or equivalent areas in the 
     United States in the lowest fifth percentile of utilization 
     based on per capita spending under this part and part A for 
     services provided in the most recent year for which data are 
     available as of the date of the enactment of this subsection, 
     as standardized to eliminate the effect of geographic 
     adjustments in payment rates.
       ``(B) Identification of counties where service is 
     furnished..--For purposes of paying the additional amount 
     specified in paragraph (1), if the Secretary uses the 5-digit 
     postal ZIP Code where the service is furnished, the dominant 
     county of the postal ZIP Code (as determined by the United 
     States Postal Service, or otherwise) shall be used to 
     determine whether the postal ZIP Code is in a county 
     described in subparagraph (A).
       ``(C) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, 1878, 
     or otherwise, respecting--
       ``(i) the identification of a county or other area under 
     subparagraph (A); or
       ``(ii) the assignment of a postal ZIP Code to a county or 
     other area under subparagraph (B).
       ``(D) Publication of list of counties; posting on 
     website.--With respect to a year for which a county or area 
     is identified under this paragraph, the Secretary shall 
     identify such counties or areas as part of the proposed and 
     final rule to implement the physician fee schedule under 
     section 1848 for the applicable year. The Secretary shall 
     post the list of counties identified under this paragraph on 
     the Internet website of the Centers for Medicare & Medicaid 
     Services.''.

     SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING 
                   INITIATIVE (PQRI).

       (a) Feedback.--Section 1848(m)(5) of the Social Security 
     Act (42 U.S.C. 1395w-4(m)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(H) Feedback.--The Secretary shall provide timely 
     feedback to eligible professionals on the performance of the 
     eligible professional with respect to satisfactorily 
     submitting data on quality measures under this subsection.''.
       (b) Appeals.--Such section is further amended--
       (1) in subparagraph (E), by striking ``There shall be'' and 
     inserting ``Except as provided in subparagraph (I), there 
     shall be''; and
       (2) by adding at the end the following new subparagraph:
       ``(I) Informal appeals process.--By not later than January 
     1, 2011, the Secretary shall establish and have in place an 
     informal process for eligible professionals to seek a review 
     of the determination that an eligible professional did not 
     satisfactorily submit data on quality measures under this 
     subsection.''.
       (c) Integration of Physician Quality Reporting and EHR 
     Reporting.--Section 1848(m) of such Act is amended by adding 
     at the end the following new paragraph:
       ``(7) Integration of physician quality reporting and ehr 
     reporting.--Not later than January 1, 2012, the Secretary 
     shall develop a plan to integrate clinical reporting on 
     quality measures under this subsection with reporting 
     requirements under subsection (o) relating to the meaningful 
     use of electronic health records. Such integration shall 
     consist of the following:
       ``(A) The development of measures, the reporting of which 
     would both demonstrate--

[[Page 27262]]

       ``(i) meaningful use of an electronic health record for 
     purposes of subsection (o); and
       ``(ii) clinical quality of care furnished to an individual.
       ``(B) The collection of health data to identify 
     deficiencies in the quality and coordination of care for 
     individuals eligible for benefits under this part.
       ``(C) Such other activities as specified by the 
     Secretary.''.
       (d) Extension of Incentive Payments.--Section 1848(m)(1) of 
     such Act (42 U.S.C. 1395w-4(m)(1)) is amended--
       (1) in subparagraph (A), by striking ``2010'' and inserting 
     ``2012''; and
       (2) in subparagraph (B)(ii), by striking ``2009 and 2010'' 
     and inserting ``for each of the years 2009 through 2012''.

     SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.

       (a) In General.--Section 1848(e) of the Social Security Act 
     (42 U.S.C.1395w-4(e)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Transition to use of msas as fee schedule areas in 
     california.--
       ``(A) In general.--
       ``(i) Revision.--Subject to clause (ii) and notwithstanding 
     the previous provisions of this subsection, for services 
     furnished on or after January 1, 2011, the Secretary shall 
     revise the fee schedule areas used for payment under this 
     section applicable to the State of California using the 
     Metropolitan Statistical Area (MSA) iterative Geographic 
     Adjustment Factor methodology as follows:

       ``(I) The Secretary shall configure the physician fee 
     schedule areas using the Metropolitan Statistical Areas (each 
     in this paragraph referred to as an `MSA'), as defined by the 
     Director of the Office of Management and Budget and published 
     in the Federal Register, using the most recent available 
     decennial population data as of the date of the enactment of 
     the Affordable Health Care for America Act, as the basis for 
     the fee schedule areas.
       ``(II) For purposes of this clause, the Secretary shall 
     treat all areas not included in an MSA as a single rest of 
     the State MSA.
       ``(III) The Secretary shall list all MSAs within the State 
     by Geographic Adjustment Factor described in paragraph (2) 
     (in this paragraph referred to as a `GAF') in descending 
     order.
       ``(IV) In the first iteration, the Secretary shall compare 
     the GAF of the highest cost MSA in the State to the weighted-
     average GAF of all the remaining MSAs in the State (including 
     the rest of State MSA described in subclause (II)). If the 
     ratio of the GAF of the highest cost MSA to the weighted-
     average of the GAF of remaining lower cost MSAs is 1.05 or 
     greater, the highest cost MSA shall be a separate fee 
     schedule area.
       ``(V) In the next iteration, the Secretary shall compare 
     the GAF of the MSA with the second-highest GAF to the 
     weighted-average GAF of the all the remaining MSAs (excluding 
     MSAs that become separate fee schedule areas). If the ratio 
     of the second-highest MSA's GAF to the weighted-average of 
     the remaining lower cost MSAs is 1.05 or greater, the second-
     highest MSA shall be a separate fee schedule area. ``(VI) The 
     iterative process shall continue until the ratio of the GAF 
     of the MSA with highest remaining GAF to the weighted-average 
     of the remaining MSAs with lower GAFS is less than 1.05, and 
     the remaining group of MSAs with lower GAFS shall be treated 
     as a single fee schedule area.
       ``(VI) For purposes of the iterative process described in 
     this clause, if two MSAs have identical GAFs, they shall be 
     combined.

       ``(ii) Transition.--For services furnished on or after 
     January 1, 2011, and before January 1, 2016, in the State of 
     California, after calculating the work, practice expense, and 
     malpractice geographic indices that would otherwise be 
     determined under clauses (i), (ii), and (iii) of paragraph 
     (1)(A) for a fee schedule area determined under clause (i), 
     if the index for a county within a fee schedule area is less 
     than the index in effect for such county on December 31, 
     2010, the Secretary shall instead apply the index in effect 
     for such county on such date.
       ``(B) Subsequent revisions.--After the transition described 
     in subparagraph (A)(ii), not less than every 3 years the 
     Secretary shall review and update the fee schedule areas 
     using the methodology described in subparagraph (A)(i) and 
     any updated MSAs as defined by the Director of the Office of 
     Management and Budget and published in the Federal Register. 
     The Secretary shall review and make any changes pursuant to 
     such reviews concurrent with the application of the periodic 
     review of the adjustment factors required under paragraph 
     (1)(C) for California.
       ``(C) References to fee schedule areas.--Effective for 
     services furnished on or after January 1, 2011, for the State 
     of California, any reference in this section to a fee 
     schedule area shall be deemed a reference to an MSA in the 
     State (including the single rest of state MSA described in 
     subparagraph (A)(i)(II)).''.
       (b) Conforming Amendment to Definition of Fee Schedule 
     Area.--Section 1848(j)(2) of the Social Security Act (42 
     U.S.C. 1395w(j)(2)) is amended by striking ``The term'' and 
     inserting ``Except as provided in subsection (e)(6)(C), the 
     term''.

                     PART 2--MARKET BASKET UPDATES

     SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO 
                   MARKET BASKET UPDATES THAT DO NOT ALREADY 
                   INCORPORATE SUCH IMPROVEMENTS.

       (a) Outpatient Hospitals.--
       (1) In general.--Section 1833(t)(3)(C)(iv) of the Social 
     Security Act (42 U.S.C. 1395l(t)(3)(C)(iv)) is amended----
       (A) in the first sentence--
       (i) by inserting ``(which is subject to the productivity 
     adjustment described in subclause (II) of such section)'' 
     after ``1886(b)(3)(B)(iii)''; and
       (ii) by inserting ``(but not below 0)'' after ``reduced''; 
     and
       (B) in the second sentence, by inserting ``and which is 
     subject, beginning with 2010, to the productivity adjustment 
     described in section 1886(b)(3)(B)(iii)(II)''.
       (2) Effective date.--The amendments made by this subsection 
     shall apply to increase factors for services furnished in 
     years beginning with 2010.
       (b) Ambulance Services.--Section 1834(l)(3)(B) of such Act 
     (42 U.S.C. 1395m(l)(3)(B))) is amended by inserting before 
     the period at the end the following: ``and, in the case of 
     years beginning with 2010, subject to the productivity 
     adjustment described in section 1886(b)(3)(B)(iii)(II)''.
       (c) Ambulatory Surgical Center Services.--Section 
     1833(i)(2)(D) of such Act (42 U.S.C. 1395l(i)(2)(D)) is 
     amended--
       (1) by redesignating clause (v) as clause (vi); and
       (2) by inserting after clause (iv) the following new 
     clause:
       ``(v) In implementing the system described in clause (i), 
     for services furnished during 2010 or any subsequent year, to 
     the extent that an annual percentage change factor applies, 
     such factor shall be subject to the productivity adjustment 
     described in section 1886(b)(3)(B)(iii)(II).''.
       (d) Laboratory Services.--Section 1833(h)(2)(A) of such Act 
     (42 U.S.C. 1395l(h)(2)(A)) is amended--
       (1) in clause (i), by striking ``for each of the years 2009 
     through 2013'' and inserting ``for 2009''; and
       (2) clause (ii)--
       (A) by striking ``and'' at the end of subclause (III);
       (B) by striking the period at the end of subclause (IV) and 
     inserting ``; and''; and
       (C) by adding at the end the following new subclause:
       ``(V) the annual adjustment in the fee schedules determined 
     under clause (i) for years beginning with 2010 shall be 
     subject to the productivity adjustment described in section 
     1886(b)(3)(B)(iii)(II).''.
       (e) Certain Durable Medical Equipment.--Section 1834(a)(14) 
     of such Act (42 U.S.C. 1395m(a)(14)) is amended--
       (1) in subparagraph (K), by inserting before the semicolon 
     at the end the following: ``, subject to the productivity 
     adjustment described in section 1886(b)(3)(B)(iii)(II)'';
       (2) in subparagraph (L)(i), by inserting after ``June 
     2013,'' the following: ``subject to the productivity 
     adjustment described in section 1886(b)(3)(B)(iii)(II),'';
       (3) in subparagraph (L)(ii), by inserting after ``June 
     2013'' the following: ``, subject to the productivity 
     adjustment described in section 1886(b)(3)(B)(iii)(II)''; and
       (4) in subparagraph (M), by inserting before the period at 
     the end the following: ``, subject to the productivity 
     adjustment described in section 1886(b)(3)(B)(iii)(II)''.

                        PART 3--OTHER PROVISIONS

     SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.

       (a) In General.--Section 1834(a)(7)(A)(iii) of the Social 
     Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended--
       (1) in the heading, by inserting ``certain complex 
     rehabilitative'' after ``option for''; and
       (2) by striking ``power-driven wheelchair'' and inserting 
     ``complex rehabilitative power-driven wheelchair recognized 
     by the Secretary as classified within group 3 or higher''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect on January 1, 2011, and shall apply to 
     power-driven wheelchairs furnished on or after such date. 
     Such amendments shall not apply to contracts entered into 
     under section 1847 of the Social Security Act (42 U.S.C. 
     1395w-3) pursuant to a bid submitted under such section 
     before October 1, 2010, under subsection (a)(1)(B)(i)(I) of 
     such section.

     SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DECLINE 
                   OWNERSHIP, OF A CERTAIN ITEM OF COMPLEX DURABLE 
                   MEDICAL EQUIPMENT AFTER THE 13-MONTH CAPPED 
                   RENTAL PERIOD ENDS.

       (a) In General.--Section 1834(a)(7)(A) of the Social 
     Security Act (42 U.S.C. 1395m(a)(7)(A)) is amended--
       (1) in clause (ii)--
       (A) by striking ``rental.--On'' and inserting ``rental.--

       ``(I) In general.--Except as provided in subclause (II), 
     on''; and

       (B) by adding at the end the following new subclause:

       ``(II) Option to accept or reject transfer of title to 
     group 3 support surface.--

       ``(aa) In general.--During the 10th continuous month during 
     which payment is made

[[Page 27263]]

     for the rental of a Group 3 Support Surface under clause (i), 
     the supplier of such item shall offer the individual the 
     option to accept or reject transfer of title to a Group 3 
     Support Surface after the 13th continuous month during which 
     payment is made for the rental of the Group 3 Support Surface 
     under clause (i). Such title shall be transferred to the 
     individual only if the individual notifies the supplier not 
     later than 1 month after the supplier makes such offer that 
     the individual agrees to accept transfer of the title to the 
     Group 3 Support Surface. Unless the individual accepts 
     transfer of title to the Group 3 Support Surface in the 
     manner set forth in this subclause, the individual shall be 
     deemed to have rejected transfer of title. If the individual 
     agrees to accept the transfer of the title to the Group 3 
     Support Surface, the supplier shall transfer such title to 
     the individual on the first day that begins after the 13th 
     continuous month during which payment is made for the rental 
     of the Group 3 Support Surface under clause (i).
       ``(bb) Special rule.--If, on the effective date of this 
     subclause, an individual's rental period for a Group 3 
     Support Surface has exceeded 10 continuous months, but the 
     first day that begins after the 13th continuous month during 
     which payment is made for the rental under clause (i) has not 
     been reached, the supplier shall, within 1 month following 
     such effective date, offer the individual the option to 
     accept or reject transfer of title to a Group 3 Support 
     Surface. Such title shall be transferred to the individual 
     only if the individual notifies the supplier not later than 1 
     month after the supplier makes such offer that the individual 
     agrees to accept transfer of title to the Group 3 Support 
     Surface. Unless the individual accepts transfer of title to 
     the Group 3 Support Surface in the manner set forth in this 
     subclause, the individual shall be deemed to have rejected 
     transfer of title. If the individual agrees to accept the 
     transfer of the title to the Group 3 Support Surface, the 
     supplier shall transfer such title to the individual on the 
     first day that begins after the 13th continuous month during 
     which payment is made for the rental of the Group 3 Support 
     Surface under clause (i) unless that day has passed, in which 
     case the supplier shall transfer such title to the individual 
     not later than 1 month after notification that the individual 
     accepts transfer of title.
       ``(cc) Treatment of subsequent resupply within period of 
     reasonable useful lifetime of group 3 support surface in case 
     of need.--If an individual rejects transfer of title to a 
     Group 3 Support Surface under this subclause and the 
     individual requires such Support Surface at any subsequent 
     time during the period of the reasonable useful lifetime of 
     such equipment (as defined by the Secretary) beginning with 
     the first month for which payment is made for the rental of 
     such equipment under clause (i), the supplier shall supply 
     the equipment without charge to the individual or the program 
     under this title during the remainder of such period, other 
     than payment for maintenance and servicing during such period 
     which would otherwise have been paid if the individual had 
     accepted title to such equipment. The previous sentence shall 
     not affect the payment of amounts under this part for such 
     equipment after the end of such period of the reasonable 
     useful lifetime of the equipment.
       ``(dd) Payments.--Maintenance and servicing payments shall 
     be made in accordance with clause (iv), in the case of a 
     supplier that transfers title to the Group 3 Support Surface 
     under this subclause, after such transfer and, in the case of 
     an individual who rejects transfer of title under this 
     subclause, after the end of the period of medical need during 
     which payment is made under clause (i).''; and
       (2) in clause (iv), by inserting ``or, in the case of an 
     individual who rejects transfer of title to a Group 3 Support 
     Surface under clause (ii), after the end of the period of 
     medical need during which payment is made under clause (i),'' 
     after ``under clause (ii)''.
       (b) Effective Date.--The amendments made by this section 
     shall apply with respect to durable medical equipment not 
     later than January 1, 2011.

     SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.

        Section 1833(t)(16)(C) of the Social Security Act (42 
     U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (Public Law 110-275), is amended by striking, the first place 
     it appears, ``January 1, 2010'' and inserting ``January 1, 
     2012''.

     SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.

       Not later than July 1, 2011, the Medicare Payment Advisory 
     Commission shall submit to Congress a report on the 
     following:
       (1) The scope of coverage for home infusion therapy in the 
     fee-for-service Medicare program under title XVIII of the 
     Social Security Act, Medicare Advantage under part C of such 
     title, the veteran's health care program under chapter 17 of 
     title 38, United States Code, and among private payers, 
     including an analysis of the scope of services provided by 
     home infusion therapy providers to their patients in such 
     programs.
       (2) The benefits and costs of providing such coverage under 
     the Medicare program, including a calculation of the 
     potential savings achieved through avoided or shortened 
     hospital and nursing home stays as a result of Medicare 
     coverage of home infusion therapy.
       (3) An assessment of sources of data on the costs of home 
     infusion therapy that might be used to construct payment 
     mechanisms in the Medicare program.
       (4) Recommendations, if any, on the structure of a payment 
     system under the Medicare program for home infusion therapy, 
     including an analysis of the payment methodologies used under 
     Medicare Advantage plans and private health plans for the 
     provision of home infusion therapy and their applicability to 
     the Medicare program.

     SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO 
                   SUBMIT COST DATA AND OTHER DATA.

       (a) Cost Reporting.--
       (1) In general.--Section 1833(i) of the Social Security Act 
     (42 U.S.C. 1395l(i)) is amended by adding at the end the 
     following new paragraph:
       ``(8) The Secretary shall require, as a condition of the 
     agreement described in section 1832(a)(2)(F)(i), the 
     submission of such cost report as the Secretary may specify, 
     taking into account the requirements for such reports under 
     section 1815 in the case of a hospital.''.
       (2) Development of cost report.--Not later than 3 years 
     after the date of the enactment of this Act, the Secretary of 
     Health and Human Services shall develop a cost report form 
     for use under section 1833(i)(8) of the Social Security Act, 
     as added by paragraph (1).
       (3) Audit requirement.--The Secretary shall provide for 
     periodic auditing of cost reports submitted under section 
     1833(i)(8) of the Social Security Act, as added by paragraph 
     (1).
       (4) Effective date.--The amendment made by paragraph (1) 
     shall apply to agreements applicable to cost reporting 
     periods beginning 18 months after the date the Secretary 
     develops the cost report form under paragraph (2).
       (b) Additional Data on Quality.--
       (1) In general.--Section 1833(i)(7) of such Act (42 U.S.C. 
     1395l(i)(7)) is amended--
       (A) in subparagraph (B), by inserting ``subject to 
     subparagraph (C),'' after ``may otherwise provide,''; and
       (B) by adding at the end the following new subparagraph:
       ``(C) Under subparagraph (B) the Secretary shall require 
     the reporting of such additional data relating to quality of 
     services furnished in an ambulatory surgical facility, 
     including data on health care associated infections, as the 
     Secretary may specify.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall to reporting for years beginning with 2012.

     SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.

       Section 1833(t) of the Social Security Act (42 U.S.C. 
     1395l(t)) is amended by adding at the end the following new 
     paragraph:
       ``(18) Authorization of adjustment for cancer hospitals.--
       ``(A) Study.--The Secretary shall conduct a study to 
     determine if, under the system under this subsection, costs 
     incurred by hospitals described in section 1886(d)(1)(B)(v) 
     with respect to ambulatory payment classification groups 
     exceed those costs incurred by other hospitals furnishing 
     services under this subsection (as determined appropriate by 
     the Secretary).
       ``(B) Authorization of adjustment.--Insofar as the 
     Secretary determines under subparagraph (A) that costs 
     incurred by hospitals described in section 1886(d)(1)(B)(v) 
     exceed those costs incurred by other hospitals furnishing 
     services under this subsection, the Secretary shall provide 
     for an appropriate adjustment under paragraph (2)(E) to 
     reflect those higher costs effective for services furnished 
     on or after January 1, 2011.''.

     SEC. 1146. PAYMENT FOR IMAGING SERVICES.

       (a) Adjustment in Practice Expense to Reflect a Presumed 
     Level of Utilization.--Section 1848 of the Social Security 
     Act (42 U.S.C. 1395w-4) is amended--
       (1) in subsection (b)(4)--
       (A) in subparagraph (B), by striking ``subparagraph (A)'' 
     and inserting ``this paragraph''; and
       (B) by adding at the end the following new subparagraph:
       ``(C) Adjustment in practice expense to reflect a presumed 
     level of utilization.--Consistent with the methodology for 
     computing the number of practice expense relative value units 
     under subsection (c)(2)(C)(ii) with respect to advanced 
     diagnostic imaging services (as defined in section 
     1834(e)(1)(B)) furnished on or after January 1, 2011, the 
     Secretary shall adjust such number of units so it reflects a 
     presumed rate of utilization of imaging equipment of 75 
     percent.''; and
       (2) in subsection (c)(2)(B)(v)), by adding at the end the 
     following new subclause:

       ``(III) Change in presumed utilization level of certain 
     advanced diagnostic imaging services.--Effective for fee 
     schedules established beginning with 2011, reduced 
     expenditures attributable to the presumed utilization of 75 
     percent under subsection (b)(4)(C) instead of a presumed 
     utilization of imaging equipment of 50 percent.''.

       (b) Adjustment in Technical Component ``discount'' on 
     Single-session Imaging to

[[Page 27264]]

     Consecutive Body Parts.--Section 1848 of such Act (42 U.S.C. 
     1395w-4) is further amended--
       (1) in subsection (b)(4), by adding at the end the 
     following new subparagraph:
       ``(D) Adjustment in technical component discount on single-
     session imaging involving consecutive body parts.--For 
     services furnished on or after January 1, 2011, the Secretary 
     shall increase the reduction in expenditures attributable to 
     the multiple procedure payment reduction applicable to the 
     technical component for imaging under the final rule 
     published by the Secretary in the Federal Register on 
     November 21, 2005 (part 405 of title 42, Code of Federal 
     Regulations) from 25 percent to 50 percent.''; and
       (2) in subsection (c)(2)(B)(v), by adding at the end the 
     following new subclause:

       ``(III) Additional reduced payment for multiple imaging 
     procedures.--Effective for fee schedules established 
     beginning with 2011, reduced expenditures attributable to the 
     increase in the multiple procedure payment reduction from 25 
     percent to 50 percent as described in subsection 
     (b)(4)(D).''.

     SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.

       (a) Waiver of Surety Bond Requirement.--Section 1834(a)(16) 
     of the Social Security Act (42 U.S.C. 1395m(a)(16)) is 
     amended by adding at the end the following sentence: ``The 
     requirement for a surety bond described in subparagraph (B) 
     shall not apply in the case of a pharmacy or supplier that 
     exclusively furnishes eyeglasses or contact lenses described 
     in section 1861(s)(8) if the pharmacy or supply has been 
     enrolled under section 1866(j) as a supplier of durable 
     medical equipment, prosthetics, orthotics, and supplies and 
     has been issued (which may include renewal of) a supplier 
     number (as described in the first sentence of this paragraph) 
     for at least 5 years, and if a final adverse action (as 
     defined in section 424.57(a) of title 42, Code of Federal 
     Regulations) has never been imposed for such pharmacy or 
     supplier.''.
       (b) Ensuring Supply of Oxygen Equipment.--
       (1) In general.--Section 1834(a)(5)(F) of the Social 
     Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
       (A) in clause (ii), by striking ``After the'' and inserting 
     ``Except as provided in clause (iii), after the''; and
       (B) by adding at the end the following new clause:
       ``(iii) Continuation of supply.--In the case of a supplier 
     furnishing such equipment to an individual under this 
     subsection as of the 27th month of the 36 months described in 
     clause (i), the supplier furnishing such equipment as of such 
     month shall continue to furnish such equipment to such 
     individual (either directly or though arrangements with other 
     suppliers of such equipment) during any subsequent period of 
     medical need for the remainder of the reasonable useful 
     lifetime of the equipment, as determined by the Secretary, 
     regardless of the location of the individual, unless another 
     supplier has accepted responsibility for continuing to 
     furnish such equipment during the remainder of such 
     period.''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall take effect as of the date of the enactment of this Act 
     and shall apply to the furnishing of equipment to individuals 
     for whom the 27th month of a continuous period of use of 
     oxygen equipment described in section 1834(a)(5)(F) of the 
     Social Security Act occurs on or after July 1, 2010.
       (c) Treatment of Current Accreditation Applications.--
     Section 1834(a)(20)(F) of such Act (42 U.S.C. 
     1395m(a)(20)(F)) is amended--
       (1) in clause (i)--
       (A) by striking ``clause (ii)'' and inserting ``clauses 
     (ii) and (iii)''; and
       (B) by striking ``and'' at the end;
       (2) by striking the period at the end of clause (ii)(II) 
     and by inserting a semicolon;
       (3) by inserting after clause (ii) the following new 
     clauses:
       ``(iii) the requirement for accreditation described in 
     clause (i) shall not apply for purposes of supplying diabetic 
     testing supplies, canes, and crutches in the case of a 
     pharmacy that is enrolled under section 1866(j) as a supplier 
     of durable medical equipment, prosthetics, orthotics, and 
     supplies; and
       ``(iv) a supplier that has submitted an application for 
     accreditation before August 1, 2009, shall retain the 
     supplier's provider or supplier number until an independent 
     accreditation organization determines if such supplier 
     complies with requirements under this paragraph.''; and
       (4) by adding at the end the following new sentence: 
     ``Nothing in clauses (iii) and (iv) shall be construed as 
     affecting the application of an accreditation requirement for 
     suppliers to qualify for bidding in a competitive acquisition 
     area under section 1847,''.
       (d) Restoring 36-month Oxygen Rental Period in Case of 
     Supplier Bankruptcy for Certain Individuals.--Section 
     1834(a)(5)(F) of such Act (42 U.S.C. 1395m(a)(5)(F)), as 
     amended by subsection (b), is further amended by adding at 
     the end the following new clause:
       ``(iv) Exception for bankruptcy.--If a supplier who 
     furnishes oxygen and oxygen equipment to an individual is 
     declared bankrupt and its assets are liquidated and at the 
     time of such declaration and liquidation more than 24 months 
     of rental payments have been made, such individual may begin 
     a new 36-month rental period under this subparagraph with 
     another supplier of oxygen.''.

     SEC. 1148. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.

       (a) In General.--The Medicare Payment Advisory Commission 
     shall conduct a study regarding bone mass measurement, 
     including computed tomography, duel-energy x-ray 
     absorptriometry, and vertebral fracture assessment. The study 
     shall focus on the following:
       (1) An assessment of the adequacy of Medicare payment rates 
     for such services, taking into account costs of acquiring the 
     necessary equipment, professional work time, and practice 
     expense costs.
       (2) The impact of Medicare payment changes since 2006 on 
     beneficiary access to bone mass measurement benefits in 
     general and in rural and minority communities specifically.
       (3) A review of the clinically appropriate and recommended 
     use among Medicare beneficiaries and how usage rates among 
     such beneficiaries compares to such recommendations.
       (4) In conjunction with the findings under (3), 
     recommendations, if necessary, regarding methods for reaching 
     appropriate use of bone mass measurement studies among 
     Medicare beneficiaries.
       (b) Report.--The Commission shall submit a report to the 
     Congress, not later than 9 months after the date of the 
     enactment of this Act, containing a description of the 
     results of the study conducted under subsection (a) and the 
     conclusions and recommendations, if any, regarding each of 
     the issues described in paragraphs (1), (2) (3) and (4) of 
     such subsection.

     SEC. 1149. TIMELY ACCESS TO POST-MASTECTOMY ITEMS.

       (a) In General.--Section 1834(h)(1) of the Social Security 
     Act (42 U.S.C. 1395m) is amended--
       (1) by redesignating subparagraph (H) as subparagraph (I); 
     and
       (2) by inserting after subparagraph (G) the following new 
     subparagraph:
       ``(H) Special payment rule for post-mastectomy external 
     breast prosthesis garments.--Payment for post-mastectomy 
     external breast prosthesis garments shall be made regardless 
     of whether such items are supplied to the beneficiary prior 
     to or after the mastectomy procedure or other breast cancer 
     surgical procedure. The Secretary shall develop policies to 
     ensure appropriate beneficiary access and utilization 
     safeguards for such items supplied to a beneficiary prior to 
     the mastectomy or other breast cancer surgical procedure.''
       (b) Effective Date.--This amendment shall apply not later 
     than January 1, 2011.

     SEC. 1149A. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.

       (a) In General.--Section 1847A of the Social Security Act 
     (42 U.S.C. 1395w-3a) is amended--
       (1) in subsection (b)(1)--
       (A) in subparagraph (A), by striking ``or'' at the end;
       (B) in subparagraph (B), by striking the period at the end 
     and inserting ``; or''; and
       (C) by adding at the end the following new subparagraph:
       ``(C) in the case of one or more interchangeable biological 
     products (as defined in subsection (c)(6)(I)) and their 
     reference biological product (as defined in subsection 
     (c)(6)(J)), which shall be included in the same billing and 
     payment code, the sum of--
       ``(i) the average sales price as determined using the 
     methodology described in paragraph (6) applied to such 
     interchangeable and reference products for all National Drug 
     Codes assigned to such products in the same manner as such 
     paragraph (6) is applied to multiple source drugs; and
       ``(ii) 6 percent of the amount determined under clause (i);
       ``(D) in the case of a biosimilar biological product (as 
     defined in subsection (c)(6)(H)), the sum of--
       ``(i) the average sales price as determined using the 
     methodology described in paragraph (4) applied to such 
     biosimilar biological product for all National Drug Codes 
     assigned to such product in the same manner as such paragraph 
     (4) is applied to a single source drug; and
       ``(ii) 6 percent of the amount determined under paragraph 
     (4) or the amount determined under subparagraph (C)(ii), as 
     the case may be, for the reference biological product (as 
     defined in subsection (c)(6)(J)); or
       ``(E) in the case of a reference biological product for 
     both an interchangeable biological product and a biosimilar 
     product, the amount determined in subparagraph (C).''; and
       (2) in subsection (c)(6)--
       (A) by amending subparagraph (D)(i) to read as follows:
       ``(i) a biological, including a reference biological 
     product for a biosimilar product, but excluding--

       ``(I) a biosimilar biological product;
       ``(II) an interchangeable biological product;
       ``(III) a reference biological product for an 
     interchangeable biological product; and
       ``(IV) a reference biological product for both an 
     interchangeable biological product and a biosimilar product; 
     or''; and

[[Page 27265]]

       (B) by adding at the end the following new subparagraphs:
       ``(H) Biosimilar biological product.--The term `biosimilar 
     biological product' means a biological product licensed as a 
     biosimilar biological product under section 351(k) of the 
     Public Health Service Act.
       ``(I) Interchangeable biological product.--The term 
     `interchangeable biological product' means a biological 
     product licensed as an interchangeable biological product 
     under section 351(k) of the Public Health Service Act
       ``(J) Reference biological product.--The term `reference 
     biological product' means the biological product that is 
     referred to in the application for a biosimilar or 
     interchangeable biological product licensed under section 
     351(k) of the Public Health Service Act.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to payments for biosimilar biological products, 
     interchangeable biological products, and reference biological 
     products beginning with the first day of the second calendar 
     quarter after the date of the enactment of this Act.

     SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE BIDDING 
                   PROCESS.

       (a) Study.--The Comptroller General of the United States 
     shall conduct a study to evaluate the potential establishment 
     of a program under Medicare under title XVIII of the Social 
     Security Act to acquire durable medical equipment and 
     supplies through a competitive bidding process among 
     manufacturers of such equipment and supplies. Such study 
     shall address the following:
       (1) Identification of types of durable medical equipment 
     and supplies that would be appropriate for bidding under such 
     a program.
       (2) Recommendations on how to structure such an acquisition 
     program in order to promote fiscal responsibility while also 
     ensuring beneficiary access to high quality equipment and 
     supplies.
       (3) Recommendations on how such a program could be phased-
     in and on what geographic level would bidding be most 
     appropriate.
       (4) In addition to price, recommendations on criteria that 
     could be factored into the bidding process.
       (5) Recommendations on how suppliers could be compensated 
     for furnishing and servicing equipment and supplies acquired 
     under such a program.
       (6) Comparison of such a program to the current competitive 
     bidding program under Medicare for durable medical equipment, 
     as well as any other similar Federal acquisition programs, 
     such as the General Services Administration's vehicle 
     purchasing program.
       (7) Any other consideration relevant to the acquisition, 
     supply, and service of durable medical equipment and supplies 
     that is deemed appropriate by the Comptroller General.
       (b) Report.--Not later than 12 months after the date of the 
     enactment of this Act, the Comptroller General of the United 
     States shall submit to Congress a report on the findings of 
     the study under subsection (a).

        Subtitle C--Provisions Related to Medicare Parts A and B

     SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL 
                   READMISSIONS.

       (a) Hospitals.--
       (1) In general.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww), as amended by section 1103(a), is amended 
     by adding at the end the following new subsection:
       ``(p) Adjustment to Hospital Payments for Excess 
     Readmissions.--
       ``(1) In general.--With respect to payment for discharges 
     from an applicable hospital (as defined in paragraph (5)(C)) 
     occurring during a fiscal year beginning on or after October 
     1, 2011, in order to account for excess readmissions in the 
     hospital, the Secretary shall reduce the payments that would 
     otherwise be made to such hospital under subsection (d) (or 
     section 1814(b)(3), as the case may be) for such a discharge 
     by an amount equal to the product of--
       ``(A) the base operating DRG payment amount (as defined in 
     paragraph (2)) for the discharge; and
       ``(B) the adjustment factor (described in paragraph (3)(A)) 
     for the hospital for the fiscal year.
       ``(2) Base operating drg payment amount.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     for purposes of this subsection, the term `base operating DRG 
     payment amount' means, with respect to a hospital for a 
     fiscal year, the payment amount that would otherwise be made 
     under subsection (d) for a discharge if this subsection did 
     not apply, reduced by any portion of such amount that is 
     attributable to payments under subparagraphs (B) and (F) of 
     paragraph (5).
       ``(B) Adjustments.--For purposes of subparagraph (A), in 
     the case of a hospital that is paid under section 1814(b)(3), 
     the term `base operating DRG payment amount' means the 
     payment amount under such section.
       ``(3) Adjustment factor.--
       ``(A) In general.--For purposes of paragraph (1), the 
     adjustment factor under this paragraph for an applicable 
     hospital for a fiscal year is equal to the greater of--
       ``(i) the ratio described in subparagraph (B) for the 
     hospital for the applicable period (as defined in paragraph 
     (5)(D)) for such fiscal year; or
       ``(ii) the floor adjustment factor specified in 
     subparagraph (C).
       ``(B) Ratio.--The ratio described in this subparagraph for 
     a hospital for an applicable period is equal to 1 minus the 
     ratio of--
       ``(i) the aggregate payments for excess readmissions (as 
     defined in paragraph (4)(A)) with respect to an applicable 
     hospital for the applicable period; and
       ``(ii) the aggregate payments for all discharges (as 
     defined in paragraph (4)(B)) with respect to such applicable 
     hospital for such applicable period.
       ``(C) Floor adjustment factor.--For purposes of 
     subparagraph (A), the floor adjustment factor specified in 
     this subparagraph for--
       ``(i) fiscal year 2012 is 0.99;
       ``(ii) fiscal year 2013 is 0.98;
       ``(iii) fiscal year 2014 is 0.97; or
       ``(iv) a subsequent fiscal year is 0.95.
       ``(4) Aggregate payments, excess readmission ratio 
     defined.--For purposes of this subsection:
       ``(A) Aggregate payments for excess readmissions.--The term 
     `aggregate payments for excess readmissions' means, for a 
     hospital for a fiscal year, the sum, for applicable 
     conditions (as defined in paragraph (5)(A)), of the product, 
     for each applicable condition, of--
       ``(i) the base operating DRG payment amount for such 
     hospital for such fiscal year for such condition;
       ``(ii) the number of admissions for such condition for such 
     hospital for such fiscal year; and
       ``(iii) the excess readmissions ratio (as defined in 
     subparagraph (C)) for such hospital for the applicable period 
     for such fiscal year minus 1.
       ``(B) Aggregate payments for all discharges.--The term 
     `aggregate payments for all discharges' means, for a hospital 
     for a fiscal year, the sum of the base operating DRG payment 
     amounts for all discharges for all conditions from such 
     hospital for such fiscal year.
       ``(C) Excess readmission ratio.--
       ``(i) In general.--Subject to clauses (ii) and (iii), the 
     term `excess readmissions ratio' means, with respect to an 
     applicable condition for a hospital for an applicable period, 
     the ratio (but not less than 1.0) of--

       ``(I) the risk adjusted readmissions based on actual 
     readmissions, as determined consistent with a readmission 
     measure methodology that has been endorsed under paragraph 
     (5)(A)(ii)(I), for an applicable hospital for such condition 
     with respect to the applicable period; to
       ``(II) the risk adjusted expected readmissions (as 
     determined consistent with such a methodology) for such 
     hospital for such condition with respect to such applicable 
     period.

       ``(ii) Exclusion of certain readmissions.--For purposes of 
     clause (i), with respect to a hospital, excess readmissions 
     shall not include readmissions for an applicable condition 
     for which there are fewer than a minimum number (as 
     determined by the Secretary) of discharges for such 
     applicable condition for the applicable period and such 
     hospital.
       ``(iii) Adjustment.--In order to promote a reduction over 
     time in the overall rate of readmissions for applicable 
     conditions, the Secretary may provide, beginning with 
     discharges for fiscal year 2014, for the determination of the 
     excess readmissions ratio under subparagraph (C) to be based 
     on a ranking of hospitals by readmission ratios (from lower 
     to higher readmission ratios) normalized to a benchmark that 
     is lower than the 50th percentile.
       ``(5) Definitions.--For purposes of this subsection:
       ``(A) Applicable condition.--The term `applicable 
     condition' means, subject to subparagraph (B), a condition or 
     procedure selected by the Secretary among conditions and 
     procedures for which--
       ``(i) readmissions (as defined in subparagraph (E)) that 
     represent conditions or procedures that are high volume or 
     high expenditures under this title (or other criteria 
     specified by the Secretary); and
       ``(ii) measures of such readmissions--

       ``(I) have been endorsed by the entity with a contract 
     under section 1890(a); and
       ``(II) such endorsed measures have appropriate exclusions 
     for readmissions that are unrelated to the prior discharge 
     (such as a planned readmission or transfer to another 
     applicable hospital).

       ``(B) Expansion of applicable conditions.--Beginning with 
     fiscal year 2013, the Secretary shall expand the applicable 
     conditions beyond the 3 conditions for which measures have 
     been endorsed as described in subparagraph (A)(ii)(I) as of 
     the date of the enactment of this subsection to the 
     additional 4 conditions that have been so identified by the 
     Medicare Payment Advisory Commission in its report to 
     Congress in June 2007 and to other conditions and procedures 
     which may include an all-condition measure of readmissions, 
     as determined appropriate by the Secretary. In expanding such 
     applicable conditions, the Secretary shall seek the 
     endorsement described in subparagraph (A)(ii)(I) but may 
     apply such measures without such an endorsement.

[[Page 27266]]

       ``(C) Applicable hospital.--The term `applicable hospital' 
     means a subsection (d) hospital or a hospital that is paid 
     under section 1814(b)(3).
       ``(D) Applicable period.--The term `applicable period' 
     means, with respect to a fiscal year, such period as the 
     Secretary shall specify for purposes of determining excess 
     readmissions.
       ``(E) Readmission.--The term `readmission' means, in the 
     case of an individual who is discharged from an applicable 
     hospital, the admission of the individual to the same or 
     another applicable hospital within a time period specified by 
     the Secretary from the date of such discharge. Insofar as the 
     discharge relates to an applicable condition for which there 
     is an endorsed measure described in subparagraph (A)(ii)(I), 
     such time period (such as 30 days) shall be consistent with 
     the time period specified for such measure.
       ``(6) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(A) the determination of base operating DRG payment 
     amounts;
       ``(B) the methodology for determining the adjustment factor 
     under paragraph (3), including excess readmissions ratio 
     under paragraph (4)(C), aggregate payments for excess 
     readmissions under paragraph (4)(A), and aggregate payments 
     for all discharges under paragraph (4)(B), and applicable 
     periods and applicable conditions under paragraph (5);
       ``(C) the measures of readmissions as described in 
     paragraph (5)(A)(ii); and
       ``(D) the determination of a targeted hospital under 
     paragraph (8)(B)(i), the increase in payment under paragraph 
     (8)(B)(ii), the aggregate cap under paragraph (8)(C)(i), the 
     hospital-specific limit under paragraph (8)(C)(ii), and the 
     form of payment made by the Secretary under paragraph (8)(D).
       ``(7) Monitoring inappropriate changes in admissions 
     practices.--The Secretary shall monitor the activities of 
     applicable hospitals to determine if such hospitals have 
     taken steps to avoid patients at risk in order to reduce the 
     likelihood of increasing readmissions for applicable 
     conditions or taken other inappropriate steps involving 
     readmissions or transfers. If the Secretary determines that 
     such a hospital has taken such a step, after notice to the 
     hospital and opportunity for the hospital to undertake action 
     to alleviate such steps, the Secretary may impose an 
     appropriate sanction.
       ``(8) Assistance to certain hospitals.--
       ``(A) In general.--For purposes of providing funds to 
     applicable hospitals to take steps described in subparagraph 
     (E) to address factors that may impact readmissions of 
     individuals who are discharged from such a hospital, for 
     fiscal years beginning on or after October 1, 2011, the 
     Secretary shall make a payment adjustment for a hospital 
     described in subparagraph (B), with respect to each such 
     fiscal year, by a percent estimated by the Secretary to be 
     consistent with subparagraph (C). The Secretary shall provide 
     priority to hospitals that serve Medicare beneficiaries at 
     highest risk for readmission or for a poor transition from 
     such a hospital to a post-hospital site of care.
       ``(B) Targeted hospitals.--Subparagraph (A) shall apply to 
     an applicable hospital that--
       ``(i) had (or, in the case of an 1814(b)(3) hospital, 
     otherwise would have had) a disproportionate patient 
     percentage (as defined in section 1886(d)(5)(F)) of at least 
     30 percent, using the latest available data as estimated by 
     the Secretary; and
       ``(ii) provides assurances satisfactory to the Secretary 
     that the increase in payment under this paragraph shall be 
     used for purposes described in subparagraph (E).
       ``(C) Caps.--
       ``(i) Aggregate cap.--The aggregate amount of the payment 
     adjustment under this paragraph for a fiscal year shall not 
     exceed 5 percent of the estimated difference in the spending 
     that would occur for such fiscal year with and without 
     application of the adjustment factor described in paragraph 
     (3) and applied pursuant to paragraph (1).
       ``(ii) Hospital-specific limit.--The aggregate amount of 
     the payment adjustment for a hospital under this paragraph 
     shall not exceed the estimated difference in spending that 
     would occur for such fiscal year for such hospital with and 
     without application of the adjustment factor described in 
     paragraph (3) and applied pursuant to paragraph (1).
       ``(D) Form of payment.--The Secretary may make the 
     additional payments under this paragraph on a lump sum basis, 
     a periodic basis, a claim by claim basis, or otherwise.
       ``(E) Use of additional payment.--
       ``(i) In general.--Funding under this paragraph shall be 
     used by targeted hospitals for activities designed to address 
     the patient noncompliance issues that result in higher than 
     normal readmission rates, including transitional care 
     services described in clause (ii) and any or all of the other 
     activities described in clause (iii).
       ``(ii) Transitional care services.--The transitional care 
     services described in this clause are transitional care 
     services furnished by a qualified transitional care provider, 
     such as a nurse or other health professional, who meets 
     relevant experience and training requirements as specified by 
     the Secretary that support a beneficiary under this section 
     beginning on the date of an individual's admission to a 
     hospital for inpatient hospital services and ending at the 
     latest on the last day of the 90-day period beginning on the 
     date of the individual's discharge from the applicable 
     hospital. The Secretary shall determine and update services 
     to be included in transitional care services under this 
     clause as appropriate, based on evidence of their 
     effectiveness in reducing hospital readmissions and improving 
     health outcomes. Such services shall include the following:

       ``(I) Conduct of an assessment prior to discharge, which 
     assessment may include an assessment of the individual's 
     physical and mental condition, cognitive and functional 
     capacities, medication regimen and adherence, social and 
     environmental needs, and primary caregiver needs and 
     resources.
       ``(II) Development of a evidence-based plan of transitional 
     care for the individual developed after consultation with the 
     individual and the individual's primary caregiver and other 
     health team members, as appropriate. Such plan shall include 
     a list of current therapies prescribed, treatment goals and 
     may include other items or elements as determined by the 
     Secretary, such as identifying list of potential health risks 
     and future services for both the individual and any primary 
     caregiver.

       ``(iii) Other activities.--The other activities described 
     in this clause are the following:

       ``(I) Providing other care coordination services not 
     described under clause (ii).
       ``(II) Hiring translators and interpreters.
       ``(III) Increasing services offered by discharge planners.
       ``(IV) Ensuring that individuals receive a summary of care 
     and medication orders upon discharge.
       ``(V) Developing a quality improvement plan to assess and 
     remedy preventable readmission rates.
       ``(VI) Assigning appropriate follow-up care for discharged 
     individuals.
       ``(VII) Doing other activities as determined appropriate by 
     the Secretary.

       ``(F) GAO report on use of funds.--Not later than 3 years 
     after the date on which funds are first made available under 
     this paragraph, the Comptroller General of the United States 
     shall submit to Congress a report on the use of such funds. 
     Such report shall consider information on the effective uses 
     of such funds, how the uses of such funds affected hospital 
     readmission rates (including at 6 months post-discharge), 
     health outcomes and quality, reductions in expenditures under 
     this title and the experiences of beneficiaries, primary 
     caregivers, and providers, as well as any appropriate 
     recommendations.''.
       (b) Application to Critical Access Hospitals.--Section 
     1814(l) of the Social Security Act (42 U.S.C. 1395f(l)) is 
     amended--
       (1) in paragraph (5)--
       (A) by striking ``and'' at the end of subparagraph (C);
       (B) by striking the period at the end of subparagraph (D) 
     and inserting ``; and'';
       (C) by inserting at the end the following new subparagraph:
       ``(E) the methodology for determining the adjustment factor 
     under paragraph (5), including the determination of aggregate 
     payments for actual and expected readmissions, applicable 
     periods, applicable conditions and measures of 
     readmissions.''; and
       (D) by redesignating such paragraph as paragraph (6); and
       (2) by inserting after paragraph (4) the following new 
     paragraph:
       ``(5) The adjustment factor described in section 1886(p)(3) 
     shall apply to payments with respect to a critical access 
     hospital with respect to a cost reporting period beginning in 
     fiscal year 2012 and each subsequent fiscal year (after 
     application of paragraph (4) of this subsection) in a manner 
     similar to the manner in which such section applies with 
     respect to a fiscal year to an applicable hospital as 
     described in section 1886(p)(2).''.
       (c) Post Acute Care Providers.--
       (1) Interim policy.--
       (A) In general.--With respect to a readmission to an 
     applicable hospital or a critical access hospital (as 
     described in section 1814(l) of the Social Security Act) from 
     a post acute care provider (as defined in paragraph (3)) and 
     such a readmission is not governed by section 412.531 of 
     title 42, Code of Federal Regulations, if the claim submitted 
     by such a post-acute care provider under title XVIII of the 
     Social Security Act indicates that the individual was 
     readmitted to a hospital from such a post-acute care provider 
     or admitted from home and under the care of a home health 
     agency within 30 days of an initial discharge from an 
     applicable hospital or critical access hospital, the payment 
     under such title on such claim shall be the applicable 
     percent specified in subparagraph (B) of the payment that 
     would otherwise be made under the respective payment system 
     under such title for such post-acute care provider if this 
     subsection did not apply. In applying the previous sentence, 
     the Secretary shall exclude a period of 1 day from the date 
     the individual is first admitted to or under the care of the 
     post-acute care provider.
       (B) Applicable percent defined.--For purposes of 
     subparagraph (A), the applicable percent is--

[[Page 27267]]

       (i) for fiscal or rate year 2012 is 0.996;
       (ii) for fiscal or rate year 2013 is 0.993; and
       (iii) for fiscal or rate year 2014 is 0.99.
       (C) Effective date.--Subparagraph (1) shall apply to 
     discharges or services furnished (as the case may be with 
     respect to the applicable post acute care provider) on or 
     after the first day of the fiscal year or rate year, 
     beginning on or after October 1, 2011, with respect to the 
     applicable post acute care provider.
       (2) Development and application of performance measures.--
       (A) In general.--The Secretary of Health and Human Services 
     shall develop appropriate measures of readmission rates for 
     post acute care providers. The Secretary shall seek 
     endorsement of such measures by the entity with a contract 
     under section 1890(a) of the Social Security Act but may 
     adopt and apply such measures under this paragraph without 
     such an endorsement. The Secretary shall expand such measures 
     in a manner similar to the manner in which applicable 
     conditions are expanded under paragraph (5)(B) of section 
     1886(p) of the Social Security Act, as added by subsection 
     (a).
       (B) Implementation.--The Secretary shall apply, on or after 
     October 1, 2014, with respect to post acute care providers, 
     policies similar to the policies applied with respect to 
     applicable hospitals and critical access hospitals under the 
     amendments made by subsection (a). The provisions of 
     paragraph (1) shall apply with respect to any period on or 
     after October 1, 2014, and before such application date 
     described in the previous sentence in the same manner as such 
     provisions apply with respect to fiscal or rate year 2014.
       (C) Monitoring and penalties.--The provisions of paragraph 
     (7) of such section 1886(p) shall apply to providers under 
     this paragraph in the same manner as they apply to hospitals 
     under such section.
       (3) Definitions.--For purposes of this subsection:
       (A) Post acute care provider.--The term ``post acute care 
     provider'' means--
       (i) a skilled nursing facility (as defined in section 
     1819(a) of the Social Security Act);
       (ii) an inpatient rehabilitation facility (described in 
     section 1886(h)(1)(A) of such Act);
       (iii) a home health agency (as defined in section 1861(o) 
     of such Act); and
       (iv) a long term care hospital (as defined in section 
     1861(ccc) of such Act).
       (B) Other terms.--The terms ``applicable condition'', 
     ``applicable hospital'', and ``readmission'' have the 
     meanings given such terms in section 1886(p)(5) of the Social 
     Security Act, as added by subsection (a)(1).
       (d) Physicians.--
       (1) Study.--The Secretary of Health and Human Services 
     shall conduct a study to determine how the readmissions 
     policy described in the previous subsections could be applied 
     to physicians.
       (2) Considerations.--In conducting the study, the Secretary 
     shall consider approaches such as--
       (A) creating a new code (or codes) and payment amount (or 
     amounts) under the fee schedule in section 1848 of the Social 
     Security Act (in a budget neutral manner) for services 
     furnished by an appropriate physician who sees an individual 
     within the first week after discharge from a hospital or 
     critical access hospital;
       (B) developing measures of rates of readmission for 
     individuals treated by physicians;
       (C) applying a payment reduction for physicians who treat 
     the patient during the initial admission that results in a 
     readmission; and
       (D) methods for attributing payments or payment reductions 
     to the appropriate physician or physicians.
       (3) Report.--The Secretary shall issue a public report on 
     such study not later than the date that is one year after the 
     date of the enactment of this Act.
       (e) Funding.--For purposes of carrying out the provisions 
     of this section, in addition to funds otherwise available, 
     out of any funds in the Treasury not otherwise appropriated, 
     there are appropriated to the Secretary of Health and Human 
     Services for the Center for Medicare & Medicaid Services 
     Program Management Account $25,000,000 for each fiscal year 
     beginning with 2010. Amounts appropriated under this 
     subsection for a fiscal year shall be available until 
     expended.

     SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND 
                   BUNDLING PILOT PROGRAM.

       (a) Plan.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     develop a detailed plan to reform payment for post acute care 
     (PAC) services under the Medicare program under title XVIII 
     of the Social Security Act (in this section referred to as 
     the ``Medicare program)''. The goals of such payment reform 
     are to--
       (A) improve the coordination, quality, and efficiency of 
     such services; and
       (B) improve outcomes for individuals such as reducing the 
     need for readmission to hospitals from providers of such 
     services.
       (2) Bundling post acute services.--The plan described in 
     paragraph (1) shall include detailed specifications for a 
     bundled payment for post acute services (in this section 
     referred to as the ``post acute care bundle''), and may 
     include other approaches determined appropriate by the 
     Secretary.
       (3) Post acute services.--For purposes of this section, the 
     term ``post acute services'' means services for which payment 
     may be made under the Medicare program that are furnished by 
     skilled nursing facilities, inpatient rehabilitation 
     facilities, long term care hospitals, hospital based 
     outpatient rehabilitation facilities and home health agencies 
     to an individual after discharge of such individual from a 
     hospital, and such other services determined appropriate by 
     the Secretary.
       (b) Details.--The plan described in subsection (a)(1) shall 
     include consideration of the following issues:
       (1) The nature of payments under a post acute care bundle, 
     including the type of provider or entity to whom payment 
     should be made, the scope of activities and services included 
     in the bundle, whether payment for physicians' services 
     should be included in the bundle, and the period covered by 
     the bundle.
       (2) Whether the payment should be consolidated with the 
     payment under the inpatient prospective system under section 
     1886 of the Social Security Act (in this section referred to 
     as MS-DRGs) or a separate payment should be established for 
     such bundle, and if a separate payment is established, 
     whether it should be made only upon use of post acute care 
     services or for every discharge.
       (3) Whether the bundle should be applied across all 
     categories of providers of inpatient services (including 
     critical access hospitals) and post acute care services or 
     whether it should be limited to certain categories of 
     providers, services, or discharges, such as high volume or 
     high cost MS-DRGs.
       (4) The extent to which payment rates could be established 
     to achieve offsets for efficiencies that could be expected to 
     be achieved with a bundle payment, whether such rates should 
     be established on a national basis or for different 
     geographic areas, should vary according to discharge, case 
     mix, outliers, and geographic differences in wages or other 
     appropriate adjustments, and how to update such rates.
       (5) The nature of protections needed for individuals under 
     a system of bundled payments to ensure that individuals 
     receive quality care, are furnished the level and amount of 
     services needed as determined by an appropriate assessment 
     instrument, are offered choice of provider, and the extent to 
     which transitional care services would improve quality of 
     care for individuals and the functioning of a bundled post-
     acute system.
       (6) The nature of relationships that may be required 
     between hospitals and providers of post acute care services 
     to facilitate bundled payments, including the application of 
     gainsharing, anti-referral, anti-kickback, and anti-trust 
     laws.
       (7) Quality measures that would be appropriate for 
     reporting by hospitals and post acute providers (such as 
     measures that assess changes in functional status and quality 
     measures appropriate for each type of post acute services 
     provider including how the reporting of such quality measures 
     could be coordinated with other reporting of such quality 
     measures by such providers otherwise required).
       (8) How cost-sharing for a post acute care bundle should be 
     treated relative to current rules for cost-sharing for 
     inpatient hospital, home health, skilled nursing facility, 
     and other services.
       (9) How other programmatic issues should be treated in a 
     post acute care bundle, including rules specific to various 
     types of post-acute providers such as the post-acute transfer 
     policy, three-day hospital stay to qualify for services 
     furnished by skilled nursing facilities, and the coordination 
     of payments and care under the Medicare program and the 
     Medicaid program.
       (10) Such other issues as the Secretary deems appropriate.
       (c) Consultations and Analysis.--
       (1) Consultation with stakeholders.--In developing the plan 
     under subsection (a)(1), the Secretary shall consult with 
     relevant stakeholders and shall consider experience with such 
     research studies and demonstrations that the Secretary 
     determines appropriate.
       (2) Analysis and data collection.--In developing such plan, 
     the Secretary shall--
       (A) analyze the issues described in subsection (b) and 
     other issues that the Secretary determines appropriate;
       (B) analyze the impacts (including geographic impacts) of 
     post acute service reform approaches, including bundling of 
     such services on individuals, hospitals, post acute care 
     providers, and physicians;
       (C) use existing data (such as data submitted on claims) 
     and collect such data as the Secretary determines are 
     appropriate to develop such plan required in this section; 
     and
       (D) if patient functional status measures are appropriate 
     for the analysis, to the extent practical, build upon the 
     CARE tool being developed pursuant to section 5008 of the 
     Deficit Reduction Act of 2005.
       (d) Administration.--
       (1) Funding.--For purposes of carrying out the provisions 
     of this section, in addition to funds otherwise available, 
     out of any funds in the Treasury not otherwise appropriated, 
     there are appropriated to the Secretary for the Center for 
     Medicare & Medicaid Services

[[Page 27268]]

     Program Management Account $15,000,000 for each of the fiscal 
     years 2010 through 2012. Amounts appropriated under this 
     paragraph for a fiscal year shall be available until 
     expended.
       (2) Expedited data collection.--Chapter 35 of title 44, 
     United States Code shall not apply to this section.
       (e) Public Reports.--
       (1) Interim reports.--The Secretary shall issue interim 
     public reports on a periodic basis on the plan described in 
     subsection (a)(1), the issues described in subsection (b), 
     and impact analyses as the Secretary determines appropriate.
       (2) Final report.--Not later than the date that is 3 years 
     after the date of the enactment of this Act, the Secretary 
     shall issue a final public report on such plan, including 
     analysis of issues described in subsection (b) and impact 
     analyses.
       (f) Conversion of Acute Care Episode Demonstration to Pilot 
     Program and Expansion to Include Post Acute Services.--
       (1) In general.--Part E of title XVIII of the Social 
     Security Act is amended by inserting after section 1866C the 
     following new section:


 ``conversion of acute care episode demonstration to pilot program and 
                expansion to include post acute services

       ``Sec. 1866D.  (a) Conversion and Expansion.--
       ``(1) In general.--By not later than January 1, 2011, the 
     Secretary shall, for the purpose of promoting the use of 
     bundled payments to promote efficient, coordinated, and high 
     quality delivery of care--
       ``(A) convert the acute care episode demonstration program 
     conducted under section 1866C to a pilot program; and
       ``(B) subject to subsection (c), expand such program as so 
     converted to include post acute services and such other 
     services the Secretary determines to be appropriate, which 
     may include transitional services.
       ``(2) Bundled payment structures.--
       ``(A) In general.--In carrying out paragraph (1), the 
     Secretary may apply bundled payments with respect to--
       ``(i) hospitals and physicians;
       ``(ii) hospitals and post-acute care providers;
       ``(iii) hospitals, physicians, and post-acute care 
     providers; or
       ``(iv) combinations of post-acute providers.
       ``(B) Further application.--
       ``(i) In general.--In carrying out paragraph (1), the 
     Secretary shall apply bundled payments in a manner so as to 
     include collaborative care networks and continuing care 
     hospitals.
       ``(ii) Collaborative care network defined.--For purposes of 
     this subparagraph, the term `collaborative care network' 
     means a consortium of health care providers that provides a 
     comprehensive range of coordinated and integrated health care 
     services to low-income patient populations (including the 
     uninsured) which may include coordinated and comprehensive 
     care by safety net providers to reduce any unnecessary use of 
     items and services furnished in emergency departments, manage 
     chronic conditions, improve quality and efficiency of care, 
     increase preventive services, and promote adherence to post-
     acute and follow-up care plans.
       ``(iii) Continuing care hospital defined.--For purposes of 
     this subparagraph, the term `continuing care hospital' means 
     an entity that has demonstrated the ability to meet patient 
     care and patient safety standards and that provides under 
     common management the medical and rehabilitation services 
     provided in inpatient rehabilitation hospitals and units (as 
     defined in section 1886(d)(1)(B)(ii)), long-term care 
     hospitals (as defined in section 1886(d)(1)(B)(iv)(I)), and 
     skilled nursing facilities (as defined in section 1819(a)) 
     that are located in a hospital described in section 1886(d).
       ``(b) Scope.--The Secretary shall set specific goals for 
     the number of acute and post-acute bundling test sites under 
     the pilot program to ensure that over time the pilot program 
     is of sufficient size and scope to--
       ``(1) test the approaches under the pilot program in a 
     variety of settings, including urban, rural, and underserved 
     areas;
       ``(2) include geographic areas and additional conditions 
     that account for significant program spending, as defined by 
     the Secretary; and
       ``(3) subject to subsection (d), disseminate the pilot 
     program rapidly on a national basis.
     To the extent that the Secretary finds inpatient and post 
     acute care bundling to be successful in improving quality and 
     reducing costs, the Secretary shall implement such mechanisms 
     and reforms under the pilot program on as large a geographic 
     scale as practical and economical, consistent with subsection 
     (e). Nothing in this subsection shall be construed as 
     limiting the number of hospital and physician groups or the 
     number of hospital and post-acute provider groups that may 
     participate in the pilot program.
       ``(c) Limitation.--The Secretary shall only expand the 
     pilot program under subsection (a) if the Secretary finds 
     that--
       ``(1) the demonstration program under section 1866C and 
     pilot program under this section maintain or increase the 
     quality of care received by individuals enrolled under this 
     title; and
       ``(2) such demonstration program and pilot program reduce 
     program expenditures and, based on the certification under 
     subsection (d), that the expansion of such pilot program 
     would result in estimated spending that would be less than 
     what spending would otherwise be in the absence of this 
     section.
       ``(d) Certification.--For purposes of subsection (c), the 
     Chief Actuary of the Centers for Medicare & Medicaid Services 
     shall certify whether expansion of the pilot program under 
     this section would result in estimated spending that would be 
     less than what spending would otherwise be in the absence of 
     this section.
       ``(e) Voluntary Participation.--Nothing in this paragraph 
     shall be construed as requiring the participation of an 
     entity in the pilot program under this section.
       ``(f) Evaluation on Cost and Quality of Care.--The 
     Secretary shall conduct an evaluation of the pilot program 
     under subsection (a) to study the effect of such program on 
     costs and quality of care. The findings of such evaluation 
     shall be included in the final report required under section 
     1152(e)(2) of the Affordable Health Care for America Act.
       ``(g) Study of Additional Bundling and Episode-based 
     Payment for Physicians' Services.--
       ``(1) In general.--The Secretary shall provide for a study 
     of and development of a plan for testing additional ways to 
     increase bundling of payments for physicians in connection 
     with an episode of care, such as in connection with 
     outpatient hospital services or services rendered in 
     physicians' offices, other than those provided under the 
     pilot program.
       ``(2) Application.--The Secretary may implement such a plan 
     through a demonstration program.''.
       (2) Conforming amendment.--Section 1866C(b) of the Social 
     Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking 
     ``The Secretary'' and inserting ``Subject to section 1866D, 
     the Secretary''.

     SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.

       Section 1895(b)(3)(B)(ii) of the Social Security Act (42 
     U.S.C. 1395fff(b)(3)(B)(ii)) is amended--
       (1) in subclause (IV), by striking ``and'';
       (2) by redesignating subclause (V) as subclause (VII); and
       (3) by inserting after subclause (IV) the following new 
     subclauses:

       ``(V) 2007, 2008, and 2009, subject to clause (v), the home 
     health market basket percentage increase;
       ``(VI) 2010, subject to clause (v), 0 percent; and''.

     SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.

       (a) Acceleration of Adjustment for Case Mix Changes.--
     Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C. 
     1395fff(b)(3)(B)) is amended--
       (1) in clause (iv), by striking ``Insofar as'' and 
     inserting ``Subject to clause (vi), insofar as''; and
       (2) by adding at the end the following new clause:
       ``(vi) Special rule for case mix changes for 2011.--

       ``(I) In general.--With respect to the case mix adjustments 
     established in section 484.220(a) of title 42, Code of 
     Federal Regulations, the Secretary shall apply, in 2010, the 
     adjustment established in paragraph (3) of such section for 
     2011, in addition to applying the adjustment established in 
     paragraph (2) for 2010.
       ``(II) Construction.--Nothing in this clause shall be 
     construed as limiting the amount of adjustment for case mix 
     for 2010 or 2011 if more recent data indicate an appropriate 
     adjustment that is greater than the amount established in the 
     section described in subclause (I).''.

       (b) Rebasing Home Health Prospective Payment Amount.--
     Section 1895(b)(3)(A) of the Social Security Act (42 U.S.C. 
     1395fff(b)(3)(A)) is amended--
       (1) in clause (i)--
       (A) in subclause (III), by inserting ``and before 2011'' 
     after ``after the period described in subclause (II)''; and
       (B) by inserting after subclause (III) the following new 
     subclauses:

       ``(IV) Subject to clause (iii)(I), for 2011, such amount 
     (or amounts) shall be adjusted by a uniform percentage 
     determined to be appropriate by the Secretary based on 
     analysis of factors such as changes in the average number and 
     types of visits in an episode, the change in intensity of 
     visits in an episode, growth in cost per episode, and other 
     factors that the Secretary considers to be relevant.
       ``(V) Subject to clause (iii)(II), for a year after 2011, 
     such a amount (or amounts) shall be equal to the amount (or 
     amounts) determined under this clause for the previous year, 
     updated under subparagraph (B).''; and

       (2) by adding at the end the following new clause:
       ``(iii) Special rule in case of inability to effect timely 
     rebasing.--

       ``(I) Application of proxy amount for 2011.--If the 
     Secretary is not able to compute the amount (or amounts) 
     under clause (i)(IV) so as to permit, on a timely basis, the 
     application of such clause for 2011, the Secretary shall 
     substitute for such amount (or amounts) 95 percent of the 
     amount (or amounts) that would otherwise be specified under 
     clause (i)(III) if it applied for 2011.

[[Page 27269]]

       ``(II) Adjustment for subsequent years based on data.--If 
     the Secretary applies subclause (I), the Secretary before 
     July 1, 2011, shall compare the amount (or amounts) applied 
     under such subclause with the amount (or amounts) that should 
     have been applied under clause (i)(IV). The Secretary shall 
     decrease or increase the prospective payment amount (or 
     amounts) under clause (i)(V) for 2012 (or, at the Secretary's 
     discretion, over a period of several years beginning with 
     2012) by the amount (if any) by which the amount (or amounts) 
     applied under subclause (I) is greater or less, respectively, 
     than the amount (or amounts) that should have been applied 
     under clause (i)(IV).''.

     SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO 
                   MARKET BASKET UPDATE FOR HOME HEALTH SERVICES.

       (a) In General.--Section 1895(b)(3)(B) of the Social 
     Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended--
       (1) in clause (iii), by inserting ``(including being 
     subject to the productivity adjustment described in section 
     1886(b)(3)(B)(iii)(II))'' after ``in the same manner''; and
       (2) in clause (v)(I), by inserting ``(but not below 0)'' 
     after ``reduced''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to home health market basket percentage increases 
     for years beginning with 2011.

     SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME HEALTH MARGINS.

       (a) In General.--The Medicare Payment Advisory Commission 
     shall conduct a study regarding variation in performance of 
     home health agencies in an effort to explain variation in 
     Medicare margins for such agencies. Such study shall include 
     an examination of at least the following issues:
       (1) The demographic characteristics of individuals served 
     and the geographic distribution associated with 
     transportation costs.
       (2) The characteristics of such agencies, such as whether 
     such agencies operate 24 hours each day, provide charity 
     care, or are part of an integrated health system.
       (3) The socio-economic status of individuals served, such 
     as the proportion of such individuals who are dually eligible 
     for Medicare and Medicaid benefits.
       (4) The presence of severe and or chronic disease or 
     disability in individuals served, as evidenced by multiple 
     discontinuous home health episodes with a high number of 
     visits per episode.
       (5) The differences in services provided, such as therapy 
     and non-therapy services.
       (b) Report.--Not later than June 1, 2011, the Commission 
     shall submit a report to the Congress on the results of the 
     study conducted under subsection (a) and shall include in the 
     report the Commission's conclusions and recommendations, if 
     appropriate, regarding each of the issues described in 
     paragraphs (1), (2) and (3) of such subsection.

     SEC. 1155B. PERMITTING HOME HEALTH AGENCIES TO ASSIGN THE 
                   MOST APPROPRIATE SKILLED SERVICE TO MAKE THE 
                   INITIAL ASSESSMENT VISIT UNDER A MEDICARE HOME 
                   HEALTH PLAN OF CARE FOR REHABILITATION CASES.

       (a) In General.--Notwithstanding section 484.55(a)(2) of 
     title 42 of the Code of Federal Regulations or any other 
     provision of law, a home health agency may determine the most 
     appropriate skilled therapist to make the initial assessment 
     visit for an individual who is referred (and may be eligible) 
     for home health services under title XVIII of the Social 
     Security Act but who does not require skilled nursing care as 
     long as the skilled service (for which that therapist is 
     qualified to provide the service) is included as part of the 
     plan of care for home health services for such individual.
       (b) Rule of Construction.--Nothing in subsection (a) shall 
     be construed to provide for initial eligibility for coverage 
     of home health services under title XVIII of the Social 
     Security Act on the basis of a need for occupational therapy.

     SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE 
                   PROHIBITION ON CERTAIN PHYSICIAN REFERRALS MADE 
                   TO HOSPITALS.

       (a) In General.--Section 1877 of the Social Security Act 
     (42 U.S.C. 1395nn) is amended--
       (1) in subsection (d)(2)--
       (A) in subparagraph (A), by striking ``and'' at the end;
       (B) in subparagraph (B), by striking the period at the end 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(C) in the case where the entity is a hospital, the 
     hospital meets the requirements of paragraph (3)(D).'';
       (2) in subsection (d)(3)--
       (A) in subparagraph (B), by striking ``and'' at the end;
       (B) in subparagraph (C), by striking the period at the end 
     and inserting ``; and''; and
       (C) by adding at the end the following new subparagraph:
       ``(D) the hospital meets the requirements described in 
     subsection (i)(1).'';
       (3) by amending subsection (f) to read as follows:
       ``(f) Reporting and Disclosure Requirements.--
       ``(1) In general.--Each entity providing covered items or 
     services for which payment may be made under this title shall 
     provide the Secretary with the information concerning the 
     entity's ownership, investment, and compensation 
     arrangements, including--
       ``(A) the covered items and services provided by the 
     entity, and
       ``(B) the names and unique physician identification numbers 
     of all physicians with an ownership or investment interest 
     (as described in subsection (a)(2)(A)), or with a 
     compensation arrangement (as described in subsection 
     (a)(2)(B)), in the entity, or whose immediate relatives have 
     such an ownership or investment interest or who have such a 
     compensation relationship with the entity.
     Such information shall be provided in such form, manner, and 
     at such times as the Secretary shall specify. The requirement 
     of this subsection shall not apply to designated health 
     services provided outside the United States or to entities 
     which the Secretary determines provide services for which 
     payment may be made under this title very infrequently.
       ``(2) Requirements for hospitals with physician ownership 
     or investment.--In the case of a hospital that meets the 
     requirements described in subsection (i)(1), the hospital 
     shall--
       ``(A) submit to the Secretary an initial report, and 
     periodic updates at a frequency determined by the Secretary, 
     containing a detailed description of the identity of each 
     physician owner and physician investor and any other owners 
     or investors of the hospital;
       ``(B) require that any referring physician owner or 
     investor discloses to the individual being referred, by a 
     time that permits the individual to make a meaningful 
     decision regarding the receipt of services, as determined by 
     the Secretary, the ownership or investment interest, as 
     applicable, of such referring physician in the hospital; and
       ``(C) disclose the fact that the hospital is partially or 
     wholly owned by one or more physicians or has one or more 
     physician investors--
       ``(i) on any public website for the hospital; and
       ``(ii) in any public advertising for the hospital.
     The information to be reported or disclosed under this 
     paragraph shall be provided in such form, manner, and at such 
     times as the Secretary shall specify. The requirements of 
     this paragraph shall not apply to designated health services 
     furnished outside the United States or to entities which the 
     Secretary determines provide services for which payment may 
     be made under this title very infrequently.
       ``(3) Publication of information.--The Secretary shall 
     publish, and periodically update, the information submitted 
     by hospitals under paragraph (2)(A) on the public Internet 
     website of the Centers for Medicare & Medicaid Services.'';
       (4) by amending subsection (g)(5) to read as follows:
       ``(5) Failure to report or disclose information.--
       ``(A) Reporting.--Any person who is required, but fails, to 
     meet a reporting requirement of paragraphs (1) and (2)(A) of 
     subsection (f) is subject to a civil money penalty of not 
     more than $10,000 for each day for which reporting is 
     required to have been made.
       ``(B) Disclosure.--Any physician who is required, but 
     fails, to meet a disclosure requirement of subsection 
     (f)(2)(B) or a hospital that is required, but fails, to meet 
     a disclosure requirement of subsection (f)(2)(C) is subject 
     to a civil money penalty of not more than $10,000 for each 
     case in which disclosure is required to have been made.
       ``(C) Application.--The provisions of section 1128A (other 
     than the first sentence of subsection (a) and other than 
     subsection (b)) shall apply to a civil money penalty under 
     subparagraphs (A) and (B) in the same manner as such 
     provisions apply to a penalty or proceeding under section 
     1128A(a).''; and
       (5) by adding at the end the following new subsection:
       ``(i) Requirements To Qualify for Rural Provider and 
     Hospital Ownership Exceptions to Self-referral Prohibition.--
       ``(1) Requirements described.--For purposes of subsection 
     (d)(3)(D), the requirements described in this paragraph are 
     as follows:
       ``(A) Provider agreement.--The hospital had--
       ``(i) physician ownership or investment on January 1, 2009; 
     and
       ``(ii) a provider agreement under section 1866 in effect on 
     such date.
       ``(B) Prohibition on physician ownership or investment.--
     The percentage of the total value of the ownership or 
     investment interests held in the hospital, or in an entity 
     whose assets include the hospital, by physician owners or 
     investors in the aggregate does not exceed such percentage as 
     of the date of enactment of this subsection.
       ``(C) Prohibition on expansion of facility capacity.--
     Except as provided in paragraph (2), the number of operating 
     rooms, procedure rooms, or beds of the hospital at any time 
     on or after the date of the enactment of this subsection are 
     no greater than the number of operating rooms, procedure 
     rooms, or beds, respectively, as of such date.
       ``(D) Ensuring bona fide ownership and investment.--
       ``(i) Any ownership or investment interests that the 
     hospital offers to a physician are

[[Page 27270]]

     not offered on more favorable terms than the terms offered to 
     a person who is not in a position to refer patients or 
     otherwise generate business for the hospital.
       ``(ii) The hospital (or any investors in the hospital) does 
     not directly or indirectly provide loans or financing for any 
     physician owner or investor in the hospital.
       ``(iii) The hospital (or any investors in the hospital) 
     does not directly or indirectly guarantee a loan, make a 
     payment toward a loan, or otherwise subsidize a loan, for any 
     physician owner or investor or group of physician owners or 
     investors that is related to acquiring any ownership or 
     investment interest in the hospital.
       ``(iv) Ownership or investment returns are distributed to 
     each owner or investor in the hospital in an amount that is 
     directly proportional to the ownership or investment interest 
     of such owner or investor in the hospital.
       ``(v) The investment interest of the owner or investor is 
     directly proportional to the owner's or investor's capital 
     contributions made at the time the ownership or investment 
     interest is obtained.
       ``(vi) Physician owners and investors do not receive, 
     directly or indirectly, any guaranteed receipt of or right to 
     purchase other business interests related to the hospital, 
     including the purchase or lease of any property under the 
     control of other owners or investors in the hospital or 
     located near the premises of the hospital.
       ``(vii) The hospital does not offer a physician owner or 
     investor the opportunity to purchase or lease any property 
     under the control of the hospital or any other owner or 
     investor in the hospital on more favorable terms than the 
     terms offered to a person that is not a physician owner or 
     investor.
       ``(viii) The hospital does not condition any physician 
     ownership or investment interests either directly or 
     indirectly on the physician owner or investor making or 
     influencing referrals to the hospital or otherwise generating 
     business for the hospital.
       ``(E) Patient safety.--In the case of a hospital that does 
     not offer emergency services, the hospital has the capacity 
     to--
       ``(i) provide assessment and initial treatment for medical 
     emergencies; and
       ``(ii) if the hospital lacks additional capabilities 
     required to treat the emergency involved, refer and transfer 
     the patient with the medical emergency to a hospital with the 
     required capability.
       ``(F) Limitation on application to certain converted 
     facilities.--The hospital was not converted from an 
     ambulatory surgical center to a hospital on or after the date 
     of enactment of this subsection.
       ``(2) Exception to prohibition on expansion of facility 
     capacity.--
       ``(A) Process.--
       ``(i) Establishment.--The Secretary shall establish and 
     implement a process under which a hospital may apply for an 
     exception from the requirement under paragraph (1)(C).
       ``(ii) Opportunity for community input.--The process under 
     clause (i) shall provide persons and entities in the 
     community in which the hospital applying for an exception is 
     located with the opportunity to provide input with respect to 
     the application.
       ``(iii) Timing for implementation.--The Secretary shall 
     implement the process under clause (i) on the date that is 
     one month after the promulgation of regulations described in 
     clause (iv).
       ``(iv) Regulations.--Not later than the first day of the 
     month beginning 18 months after the date of the enactment of 
     this subsection, the Secretary shall promulgate regulations 
     to carry out the process under clause (i). The Secretary may 
     issue such regulations as interim final regulations.
       ``(B) Frequency.--The process described in subparagraph (A) 
     shall permit a hospital to apply for an exception up to once 
     every 2 years.
       ``(C) Permitted increase.--
       ``(i) In general.--Subject to clause (ii) and subparagraph 
     (D), a hospital granted an exception under the process 
     described in subparagraph (A) may increase the number of 
     operating rooms, procedure rooms, or beds of the hospital 
     above the baseline number of operating rooms, procedure 
     rooms, or beds, respectively, of the hospital (or, if the 
     hospital has been granted a previous exception under this 
     paragraph, above the number of operating rooms, procedure 
     rooms, or beds, respectively, of the hospital after the 
     application of the most recent increase under such an 
     exception).
       ``(ii) 100 percent increase limitation.--The Secretary 
     shall not permit an increase in the number of operating 
     rooms, procedure rooms, or beds of a hospital under clause 
     (i) to the extent such increase would result in the number of 
     operating rooms, procedure rooms, or beds of the hospital 
     exceeding 200 percent of the baseline number of operating 
     rooms, procedure rooms, or beds of the hospital.
       ``(iii) Baseline number of operating rooms, procedure 
     rooms, or beds.--In this paragraph, the term `baseline number 
     of operating rooms, procedure rooms, or beds' means the 
     number of operating rooms, procedure rooms, or beds of a 
     hospital as of the date of enactment of this subsection.
       ``(D) Increase limited to facilities on the main campus of 
     the hospital.--Any increase in the number of operating rooms, 
     procedure rooms, or beds of a hospital pursuant to this 
     paragraph may only occur in facilities on the main campus of 
     the hospital.
       ``(E) Conditions for approval of an increase in facility 
     capacity.--The Secretary may grant an exception under the 
     process described in subparagraph (A) only to a hospital 
     described in subparagraph (F) or a hospital--
       ``(i) that is located in a county in which the percentage 
     increase in the population during the most recent 5-year 
     period for which data are available is estimated to be at 
     least 150 percent of the percentage increase in the 
     population growth of the State in which the hospital is 
     located during that period, as estimated by Bureau of the 
     Census and available to the Secretary;
       ``(ii) whose annual percent of total inpatient admissions 
     that represent inpatient admissions under the program under 
     title XIX is estimated to be equal to or greater than the 
     average percent with respect to such admissions for all 
     hospitals located in the county in which the hospital is 
     located;
       ``(iii) that does not discriminate against beneficiaries of 
     Federal health care programs and does not permit physicians 
     practicing at the hospital to discriminate against such 
     beneficiaries;
       ``(iv) that is located in a State in which the average bed 
     capacity in the State is estimated to be less than the 
     national average bed capacity;
       ``(v) that has an average bed occupancy rate that is 
     estimated to be greater than the average bed occupancy rate 
     in the State in which the hospital is located; and
       ``(vi) that meets other conditions as determined by the 
     Secretary.
       ``(F) Special rule for a high medicaid facility.--A 
     hospital described in this subparagraph is a hospital that--
       ``(i) with respect to each of the 3 most recent cost 
     reporting periods for which data are available, has an annual 
     percent of total inpatient admissions that represent 
     inpatient admissions under the program under title XIX that 
     is determined by the Secretary to be greater than such 
     percent with respect to such admissions for any other 
     hospital located in the county in which the hospital is 
     located; and
       ``(ii) meets the conditions described in clauses (iii) and 
     (vi) of subparagraph (E).
       ``(G) Procedure rooms.--In this subsection, the term 
     `procedure rooms' includes rooms in which catheterizations, 
     angiographies, angiograms, and endoscopies are furnished, but 
     such term shall not include emergency rooms or departments 
     (except for rooms in which catheterizations, angiographies, 
     angiograms, and endoscopies are furnished).
       ``(H) Publication of final decisions.--Not later than 120 
     days after receiving a complete application under this 
     paragraph, the Secretary shall publish on the public Internet 
     website of the Centers for Medicare & Medicaid Services the 
     final decision with respect to such application.
       ``(I) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of the exception process under this 
     paragraph, including the establishment of such process, and 
     any determination made under such process.
       ``(3) Physician owner or investor defined.--For purposes of 
     this subsection and subsection (f)(2), the term `physician 
     owner or investor' means a physician (or an immediate family 
     member of such physician) with a direct or an indirect 
     ownership or investment interest in the hospital.
       ``(4) Patient safety requirement.--In the case of a 
     hospital to which the requirements of paragraph (1) apply, 
     insofar as the hospital admits a patient and does not have 
     any physician available on the premises 24 hours per day, 7 
     days per week, before admitting the patient--
       ``(A) the hospital shall disclose such fact to the patient; 
     and
       ``(B) following such disclosure, the hospital shall receive 
     from the patient a signed acknowledgment that the patient 
     understands such fact.
       ``(5) Clarification.--Nothing in this subsection shall be 
     construed as preventing the Secretary from terminating a 
     hospital's provider agreement if the hospital is not in 
     compliance with regulations pursuant to section 1866.''.
       (b) Verifying Compliance.--The Secretary of Health and 
     Human Services shall establish policies and procedures to 
     verify compliance with the requirements described in 
     subsections (i)(1) and (i)(4) of section 1877 of the Social 
     Security Act, as added by subsection (a)(5). The Secretary 
     may use unannounced site reviews of hospitals and audits to 
     verify compliance with such requirements.
       (c) Implementation.--
       (1) Funding.--For purposes of carrying out the amendments 
     made by subsection (a) and the provisions of subsection (b), 
     in addition to funds otherwise available, out of any funds in 
     the Treasury not otherwise appropriated there are 
     appropriated to the Secretary of Health and Human Services 
     for the Centers for Medicare & Medicaid Services Program 
     Management Account $5,000,000 for each fiscal year beginning 
     with fiscal year

[[Page 27271]]

     2010. Amounts appropriated under this paragraph for a fiscal 
     year shall be available until expended.
       (2) Administration.--Chapter 35 of title 44, United States 
     Code, shall not apply to the amendments made by subsection 
     (a) and the provisions of subsection (b).

     SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC 
                   ADJUSTMENT FACTORS UNDER MEDICARE.

       (a) In General.--The Secretary of Health and Human Services 
     shall enter into a contract with the Institute of Medicine of 
     the National Academy of Science to conduct a comprehensive 
     empirical study, and provide recommendations as appropriate, 
     on the accuracy of the geographic adjustment factors 
     established under sections 1848(e) and 1886(d)(3)(E) of the 
     Social Security Act (42 U.S.C. 1395w-4(e), 1395ww(d)(3)(E)).
       (b) Matters Included.--Such study shall include an 
     evaluation and assessment of the following with respect to 
     such adjustment factors:
       (1) Empirical validity of the adjustment factors.
       (2) Methodology used to determine the adjustment factors.
       (3) Measures used for the adjustment factors, taking into 
     account--
       (A) timeliness of data and frequency of revisions to such 
     data;
       (B) sources of data and the degree to which such data are 
     representative of costs; and
       (C) operational costs of providers who participate in 
     Medicare.
       (c) Evaluation.--Such study shall, within the context of 
     the United States health care marketplace, evaluate and 
     consider the following:
       (1) The effect of the adjustment factors on the level and 
     distribution of the health care workforce and resources, 
     including--
       (A) recruitment and retention that takes into account 
     workforce mobility between urban and rural areas;
       (B) ability of hospitals and other facilities to maintain 
     an adequate and skilled workforce; and
       (C) patient access to providers and needed medical 
     technologies.
       (2) The effect of the adjustment factors on population 
     health and quality of care.
       (3) The effect of the adjustment factors on the ability of 
     providers to furnish efficient, high value care.
       (d) Report.--The contract under subsection (a) shall 
     provide for the Institute of Medicine to submit, not later 
     than 1 year after the date of the enactment of this Act, to 
     the Secretary and the Congress a report containing results 
     and recommendations of the study conducted under this 
     section.
       (e) Funding.--There are authorized to be appropriated to 
     carry out this section such sums as may be necessary.

     SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS 
                   GEOGRAPHIC INEQUITIES.

       (a) Revision of Medicare Payment Systems.--Taking into 
     account the recommendations described in the report under 
     section 1157, and notwithstanding the geographic adjustments 
     that would otherwise apply under section 1848(e) and section 
     1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-
     4(e), 1395ww(d)(3)(E)), the Secretary of Health and Human 
     Services shall include in proposed rules applicable to the 
     rulemaking cycle for payment systems for physicians' services 
     and inpatient hospital services under sections 1848 and 
     section 1886(d) of such Act, respectively, proposals (as the 
     Secretary determines to be appropriate) to revise the 
     geographic adjustment factors used in such systems. Such 
     proposals' rules shall be contained in the next rulemaking 
     cycle following the submission to the Secretary of the report 
     described in section 1157.
       (b) Payment Adjustments.--
       (1) Funding for improvements.--For years before 2014, the 
     Secretary shall ensure that the additional expenditures 
     resulting from the implementation of the provisions of this 
     section, as estimated by the Secretary, do not exceed 
     $8,000,000,000, and do not exceed half of such amount in any 
     payment year.
       (2) Hold harmless.--In carrying out this subsection--
       (A) for payment years before 2014, the Secretary shall not 
     reduce the geographic adjustment below the factor that 
     applied for such payment system in the payment year before 
     such changes; and
       (B) for payment years beginning with 2014, the Secretary 
     shall implement the geographic adjustment in a manner that 
     does not result in any net change in aggregate expenditures 
     under title XVIII of the Social Security Act from the amount 
     of such expenditures that the Secretary estimates would have 
     occurred if no geographic adjustment had occurred under this 
     section.
       (c) Medicare Improvement Fund.--
       (1) Amounts in the Medicare Improvement Fund under section 
     1898 of the Social Security Act, as amended by paragraph (2), 
     shall be available to the Secretary to make changes to the 
     geographic adjustments factors as described in subsections 
     (a) and (b) with respect to services furnished before January 
     1, 2014. No more than one-half of such amounts shall be 
     available with respect to services furnished in any one 
     payment year.
       (2) Section 1898(b) of the Social Security Act (42 U.S.C. 
     1395iii(b)) is amended--
       (A) by amending paragraph (1)(A) to read as follows:
       ``(A) the period beginning with fiscal year 2011 and ending 
     with fiscal year 2019, $8,000,000,000; and''; and
       (B) by adding at the end the following new paragraph:
       ``(5) Adjustment for underfunding.--For fiscal year 2014 or 
     a subsequent fiscal year specified by the Secretary, the 
     amount available to the fund under subsection (a) shall be 
     increased by the Secretary's estimate of the amount (based on 
     data on actual expenditures) by which--
       ``(A) the additional expenditures resulting from the 
     implementation of subsection (a) of section 1158 of the 
     Affordable Health Care for America Act for the period before 
     fiscal year 2014, is less than
       ``(B) the maximum amount of funds available under 
     subsection (a) of such section for funding for such 
     expenditures.''.

     SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC 
                   VARIATION IN HEALTH CARE SPENDING AND PROMOTING 
                   HIGH-VALUE HEALTH CARE.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section and the succeeding section referred to as 
     the ``Secretary'') shall enter into an agreement with the 
     Institute of Medicine of the National Academies (referred to 
     in this section as the ``Institute'') to conduct a study on 
     geographic variation and growth in volume and intensity of 
     services in per capita health care spending among the 
     Medicare, Medicaid, privately insured and uninsured 
     populations. Such study may draw on recent relevant reports 
     of the Institute and shall include each of the following:
       (1) An evaluation of the extent and range of such variation 
     using various units of geographic measurement, including 
     micro areas within larger areas.
       (2) An evaluation of the extent to which geographic 
     variation can be attributed to differences in input prices; 
     health status; practice patterns; access to medical services; 
     supply of medical services; socio-economic factors, including 
     race, ethnicity, gender, age, income and educational status; 
     and provider and payer organizational models.
       (3) An evaluation of the extent to which variations in 
     spending are correlated with patient access to care, 
     insurance status, distribution of health care resources, 
     health care outcomes, and consensus-based measures of health 
     care quality.
       (4) An evaluation of the extent to which variation can be 
     attributed to physician and practitioner discretion in making 
     treatment decisions, and the degree to which discretionary 
     treatment decisions are made that could be characterized as 
     different from the best available medical evidence.
       (5) An evaluation of the extent to which variation can be 
     attributed to patient preferences and patient compliance with 
     treatment protocols.
       (6) An assessment of the degree to which variation cannot 
     be explained by empirical evidence.
       (7) For Medicare beneficiaries, An evaluation of the extent 
     to which variations in spending are correlated with insurance 
     status prior to enrollment in the Medicare program under 
     title XVIII of the Social Security Act, and 
     institutionalization status; whether beneficiaries are dually 
     eligible for the Medicare program and Medicaid under title 
     XIX of such Act; and whether beneficiaries are enrolled in 
     fee-for-service Medicare or Medicare Advantage.
       (8) An evaluation of such other factors as the Institute 
     deems appropriate.
     The Institute shall conduct public hearings and provide an 
     opportunity for comments prior to completion of the reports 
     under subsection (e).
       (b) Recommendations.--Taking into account the findings 
     under subsection (a) and the changes to the payment systems 
     made by this Act, the Institute shall recommend changes to 
     payment for items and services under parts A and B of title 
     XVIII of the Social Security Act, for addressing variation in 
     Medicare per capita spending for items and services (not 
     including add-ons for graduate medical education, 
     disproportionate share payments, and health information 
     technology, as specified in sections 1886(d)(5)(F), 
     1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), respectively, 
     of such Act) by promoting high-value care (as defined in 
     subsection (f)), with particular attention to high-volume, 
     high-cost conditions. In making such recommendations, the 
     Institute shall consider each of the following:
       (1) Measurement and reporting on quality and population 
     health.
       (2) Reducing fragmented and duplicative care.
       (3) Promoting the practice of evidence-based medicine.
       (4) Empowering patients to make value-based care decisions.
       (5) Leveraging the use of health information technology.
       (6) The role of financial and other incentives affecting 
     provision of care.
       (7) Variation in input costs.
       (8) The characteristics of the patient population, 
     including socio-economic factors (including race, ethnicity, 
     gender, age, income

[[Page 27272]]

     and educational status), and whether the beneficiaries are 
     dually eligible for the Medicare program under title XVIII of 
     the Social Security Act and Medicaid under title XIX of such 
     Act.
       (9) Other topics the Institute deems appropriate.
     In making such recommendations, the Institute shall consider 
     an appropriate phase-in that takes into account the impact of 
     payment changes on providers and facilities and preserves 
     access to care for Medicare beneficiaries.
       (c) Specific Considerations.--In making the recommendations 
     under subsection (b), the Institute shall specifically 
     address whether payment systems under title XVIII of the 
     Social Security Act for physicians and hospitals should be 
     further modified to incentivize high-value care. In so doing, 
     the Institute shall consider the adoption of a value index 
     based on a composite of appropriate measures of quality and 
     cost that would adjust provider payments on a regional or 
     provider-level basis. If the Institute finds that application 
     of such a value index would significantly incentivize 
     providers to furnish high-value care, it shall make specific 
     recommendations on how such an index would be designed and 
     implemented. In so doing, it should identify specific 
     measures of quality and cost appropriate for use in such an 
     index, and include a thorough analysis (including on a 
     geographic basis) of how payments and spending under such 
     title would be affected by such an index.
       (d) Additional Considerations.--The Institute shall 
     consider the experience of governmental and community-based 
     programs that promote high-value care.
       (e) Reports.--
       (1) Not later than April 15, 2011, the Institute shall 
     submit to the Secretary and each House of Congress a report 
     containing findings and recommendations of the study 
     conducted under this section.
       (2) Following submission of the report under paragraph (1), 
     the Institute shall use the data collected and analyzed in 
     this section to issue a subsequent report, or series of 
     reports, on how best to address geographic variation or 
     efforts to promote high-value care for items and services 
     reimbursed by private insurance or other programs. Such 
     reports shall include a comparison to the Institute's 
     findings and recommendations regarding the Medicare program. 
     Such reports, and any recommendations, would not be subject 
     to the procedures outlined in section 1160.
       (f) High-value Care Defined.--For purposes of this section, 
     the term ``high-value care'' means the efficient delivery of 
     high quality, evidence-based, patient-centered care.
       (g) Appropriations.--There is appropriated from amounts in 
     the general fund of the Treasury not otherwise appropriated 
     $10,000,000 to carry out this section. Such sums are 
     authorized to remain available until expended.

     SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL REVIEW, OF 
                   PROPOSAL TO REVISE MEDICARE PAYMENTS TO PROMOTE 
                   HIGH VALUE HEALTH CARE.

       (a) Preparation and Submission of Implementation Plans.--
       (1) Final implementation plan.--Not later than 240 days 
     after the date of receipt by the Secretary and each House of 
     Congress of the report under section 1159(e)(1), the 
     Secretary shall submit to each House of Congress a final 
     implementation plan describing proposed changes to payment 
     for items and services under parts A and B of title XVIII of 
     the Social Security Act (which may include payment for 
     inpatient and outpatient hospital services for services 
     furnished in PPS and PPS-exempt hospitals, physicians' 
     services, dialysis facility services, skilled nursing 
     facility services, home health services, hospice care, 
     clinical laboratory services, durable medical equipment, and 
     other items and services, but which shall exclude add-on 
     payments for graduate medical education, disproportionate 
     share payments, and health information technology, as 
     specified in sections 1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 
     1848(o), and 1886(n), respectively, of the Social Security 
     Act) taking into consideration, as appropriate, the 
     recommendations of the report submitted under section 
     1159(e)(1) and the changes to the payment systems made by 
     this Act. To the extent such implementation plan requires a 
     substantial change to the payment system, it shall include a 
     transition phase-in that takes into consideration possible 
     disruption to provider participation in the Medicare program 
     under title XVIII of the Social Security Act and preserves 
     access to care for Medicare beneficiaries.
       (2) Preliminary implementation plan.--Not later than 90 
     days after the date the Institute of Medicine submits to each 
     House of Congress the report under section 1159(e)(1), the 
     Secretary shall submit to each House of Congress a 
     preliminary version of the implementation plan provided for 
     under paragraph (1)(A).
       (3) No increase in budget expenditures.--The Secretary 
     shall include with the submission of the final implementation 
     plan under paragraph (1) a certification by the Chief Actuary 
     of the Centers for Medicare & Medicaid Services that over the 
     initial 10-year period in which the plan is implemented, the 
     aggregate level of net expenditures under the Medicare 
     program under title XVIII of the Social Security Act will not 
     exceed the aggregate level of such expenditures that would 
     have occurred if the plan were not implemented.
       (4) Waivers required.--To the extent the final 
     implementation plan under paragraph (1) proposes changes that 
     are not otherwise permitted under title XVIII of the Social 
     Security Act, the Secretary shall specify in the plan the 
     specific waivers required under such title to implement such 
     changes. Except as provided in subsection (c), the Secretary 
     is authorized to waive the requirements so specified in order 
     to implement such changes.
       (5) Assessment of impact.--In addition, both the 
     preliminary and final implementation plans under this 
     subsection shall include a detailed assessment of the effects 
     of the proposed payment changes by provider or supplier type 
     and State relative to the payments that would otherwise 
     apply.
       (b) Review by MedPAC and GAO.--Not later than 45 days after 
     the date the preliminary implementation plan is received by 
     each House of Congress under subsection (a)(2), the Medicare 
     Payment Advisory Committee and the Comptroller General of the 
     United States shall each evaluate such plan and submit to 
     each House of Congress a report containing its analysis and 
     recommendations regarding implementation of the plan, 
     including an analysis of the effects of the proposed changes 
     in the plan on payments and projected spending.
       (c) Implementation.--
       (1) In general.--The Secretary shall include, in applicable 
     proposed rules for the next rulemaking cycle beginning after 
     the Congressional action deadline, appropriate proposals to 
     revise payments under title XVIII of the Social Security Act 
     in accordance with the final implementation plan submitted 
     under subsection (a)(1), and the waivers specified in 
     subsection (a)(4) to the extent required to carry out such 
     plan are effective, unless a joint resolution (described in 
     subsection (d)(5)(A)) with respect to such plan is enacted by 
     not later than such deadline. If such a joint resolution is 
     enacted, the Secretary is not authorized to implement such 
     plan and the waiver authority provided under subsection 
     (a)(4) shall no longer be effective.
       (2) Congressional action deadline.--For purposes of this 
     section, the term ``Congressional action deadline'' means, 
     with respect to a final implementation plan under subsection 
     (a)(1), May 31, 2012, or, if later, the date that is 145 days 
     after the date of receipt of such plan by each House of 
     Congress under subsection (a).
       (d) Congressional Procedures.--
       (1) Introduction.--On the day on which the final 
     implementation plan is received by the House of 
     Representatives and the Senate under subsection (a), a joint 
     resolution specified in paragraph (5)(A) shall be introduced 
     in the House of Representatives by the majority leader and 
     minority leader of the House of Representatives and in the 
     Senate by the majority leader and minority leader of the 
     Senate. If either House is not in session on the day on which 
     such a plan is received, the joint resolution with respect to 
     such plan shall be introduced in that House, as provided in 
     the preceding sentence, on the first day thereafter on which 
     that House is in session.
       (2) Consideration in the house of representatives.--
       (A) Reporting and discharge.--Any committee of the House of 
     Representatives to which a joint resolution introduced under 
     paragraph (1) is referred shall report such joint resolution 
     to the House not later than 50 legislative days after the 
     applicable date of introduction of the joint resolution. If a 
     committee fails to report such joint resolution within that 
     period, a motion to discharge the committee from further 
     consideration of the joint resolution shall be in order. Such 
     a motion shall be in order only at a time designated by the 
     Speaker in the legislative schedule within two legislative 
     days after the day on which the proponent announces an 
     intention to offer the motion. Notice may not be given on an 
     anticipatory basis. Such a motion shall not be in order after 
     the last committee authorized to consider the joint 
     resolution reports it to the House or after the House has 
     disposed of a motion to discharge the joint resolution. The 
     previous question shall be considered as ordered on the 
     motion to its adoption without intervening motion except 20 
     minutes of debate equally divided and controlled by the 
     proponent and an opponent. A motion to reconsider the vote by 
     which the motion is disposed of shall not be in order.
       (B) Proceeding to consideration.--After each committee 
     authorized to consider a joint resolution reports such joint 
     resolution to the House of Representatives or has been 
     discharged from its consideration, a motion to proceed to 
     consider such joint resolution shall be in order. Such a 
     motion shall be in order only at a time designated by the 
     Speaker in the legislative schedule within two legislative 
     days after the day on which the proponent announces an 
     intention to offer the motion. Notice may not be given on an 
     anticipatory basis. Such a motion shall

[[Page 27273]]

     not be in order after the House of Representatives has 
     disposed of a motion to proceed on the joint resolution. The 
     previous question shall be considered as ordered on the 
     motion to its adoption without intervening motion. A motion 
     to reconsider the vote by which the motion is disposed of 
     shall not be in order.
       (C) Consideration.--The joint resolution shall be 
     considered in the House and shall be considered as read. All 
     points of order against a joint resolution and against its 
     consideration are waived. The previous question shall be 
     considered as ordered on the joint resolution to its passage 
     without intervening motion except two hours of debate equally 
     divided and controlled by the proponent and an opponent. A 
     motion to reconsider the vote on passage of a joint 
     resolution shall not be in order.
       (3) Consideration in the senate.--
       (A) Reporting and discharge.--Any committee of the Senate 
     to which a joint resolution introduced under paragraph (1) is 
     referred shall report such joint resolution to the Senate 
     within 50 legislative days. If a committee fails to report 
     such joint resolution at the close of the 15th legislative 
     day after its receipt by the Senate, such committee shall be 
     automatically discharged from further consideration of such 
     joint resolution and such joint resolution or joint 
     resolutions shall be placed on the calendar. A vote on final 
     passage of such joint resolution shall be taken in the Senate 
     on or before the close of the second legislative day after 
     such joint resolution is reported by the committee or 
     committees of the Senate to which it was referred, or after 
     such committee or committees have been discharged from 
     further consideration of such joint resolution.
       (B) Proceeding to consideration.--A motion in the Senate to 
     proceed to the consideration of a joint resolution shall be 
     privileged and not debatable. An amendment to such a motion 
     shall not be in order, nor shall it be in order to move to 
     reconsider the vote by which such a motion is agreed to or 
     disagreed to.
       (C) Consideration.--
       (i) Debate in the Senate on a joint resolution, and all 
     debatable motions and appeals in connection therewith, shall 
     be limited to not more than 20 hours. The time shall be 
     equally divided between, and controlled by, the majority 
     leader and the minority leader or their designees.
       (ii) Debate in the Senate on any debatable motion or appeal 
     in connection with a joint resolution shall be limited to not 
     more than 1 hour, to be equally divided between, and 
     controlled by, the mover and the manager of the resolution, 
     except that in the event the manager of the joint resolution 
     is in favor of any such motion or appeal, the time in 
     opposition thereto shall be controlled by the minority leader 
     or a designee. Such leaders, or either of them, may, from 
     time under their control on the passage of a joint 
     resolution, allot additional time to any Senator during the 
     consideration of any debatable motion or appeal.
       (iii) A motion in the Senate to further limit debate is not 
     debatable. A motion to recommit a joint resolution is not in 
     order.
       (4) Rules relating to senate and house of 
     representatives.--
       (A) Coordination with action by other house.--If, before 
     the passage by one House of a joint resolution of that House, 
     that House receives from the other House a joint resolution, 
     then the following procedures shall apply:
       (i) The joint resolution of the other House shall not be 
     referred to a committee.
       (ii) With respect to the joint resolution of the House 
     receiving the resolution, the procedure in that House shall 
     be the same as if no such joint resolution had been received 
     from the other House; but the vote on passage shall be on the 
     joint resolution of the other House.
       (B) Treatment of companion measures.--If, following passage 
     of a joint resolution in the Senate, the Senate then receives 
     the companion measure from the House of Representatives, the 
     companion measure shall not be debatable.
       (C) Rules of house of representatives and senate.--This 
     paragraph and the preceding paragraphs are enacted by 
     Congress--
       (i) as an exercise of the rulemaking power of the Senate 
     and House of Representatives, respectively, and as such it is 
     deemed a part of the rules of each House, respectively, but 
     applicable only with respect to the procedure to be followed 
     in that House in the case of a joint resolution, and it 
     supersedes other rules only to the extent that it is 
     inconsistent with such rules; and
       (ii) with full recognition of the constitutional right of 
     either House to change the rules (so far as relating to the 
     procedure of that House) at any time, in the same manner, and 
     to the same extent as in the case of any other rule of that 
     House.
       (5) Definitions.--In this section:
       (A) Joint resolution.--The term ``joint resolution'' means 
     only a joint resolution--
       (i) which does not have a preamble;
       (ii) the title of which is as follows: ``Joint resolution 
     disapproving a Medicare final implementation plan of the 
     Secretary of Health and Human Services submitted under 
     section 1160(a) of the Affordable Health Care for America 
     Act''; and
       (iii) the sole matter after the resolving clause of which 
     is as follows: ``That the Congress disapproves the final 
     implementation plan of the Secretary of Health and Human 
     Services transmitted to the Congress on----------.'', the 
     blank space being filled with the appropriate date.
       (B) Legislative day.--The term ``legislative day'' means 
     any calendar day excluding any day on which that House was 
     not in session.
       (6) Budgetary treatment.--For the purposes of consideration 
     of a joint resolution, the Chairmen of the House of 
     Representatives and Senate Committees on the Budget shall 
     exclude from the evaluation of the budgetary effects of the 
     measure, any such effects that are directly attributable to 
     disapproving a Medicare final implementation plan of the 
     Secretary submitted under subsection (a).

                 Subtitle D--Medicare Advantage Reforms

                   PART 1--PAYMENT AND ADMINISTRATION

     SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE 
                   COSTS; QUALITY BONUS PAYMENTS.

       (a) Phase-in of Payment Based on Fee-for-service Costs.--
     Section 1853 of the Social Security Act (42 U.S.C. 1395w-23) 
     is amended--
       (1) in subsection (j)(1)(A)--
       (A) by striking ``beginning with 2007'' and inserting ``for 
     2007, 2008, 2009, and 2010''; and
       (B) by inserting after ``(k)(1)'' the following: ``, or, 
     beginning with 2011, \1/12\ of the blended benchmark amount 
     determined under subsection (n)(1)''; and
       (2) by adding at the end the following new subsection:
       ``(n) Determination of Blended Benchmark Amount.--
       ``(1) In general.--For purposes of subsection (j), subject 
     to paragraphs (3) and (4), the term `blended benchmark 
     amount' means for an area--
       ``(A) for 2011 the sum of--
       ``(i) \2/3\ of the applicable amount (as defined in 
     subsection (k)) for the area and year; and
       ``(ii) \1/3\ of the amount specified in paragraph (2) for 
     the area and year;
       ``(B) for 2012 the sum of--
       ``(i) \1/3\ of the applicable amount for the area and year; 
     and
       ``(ii) \2/3\ of the amount specified in paragraph (2) for 
     the area and year; and
       ``(C) for a subsequent year the amount specified in 
     paragraph (2) for the area and year.
       ``(2) Specified amount.--The amount specified in this 
     paragraph for an area and year is the amount specified in 
     subsection (c)(1)(D)(i) for the area and year adjusted (in a 
     manner specified by the Secretary) to take into account the 
     phase-out in the indirect costs of medical education from 
     capitation rates described in subsection (k)(4).
       ``(3) Fee-for-service payment floor.--In no case shall the 
     blended benchmark amount for an area and year be less than 
     the amount specified in paragraph (2).
       ``(4) Exception for pace plans.--This subsection shall not 
     apply to payments to a PACE program under section 1894.''.
       (b) Quality Bonus Payments.--Section 1853 of the Social 
     Security Act (42 U.S.C. 1395w–23), as amended by 
     subsection (a), is amended--
       (1) in subsection (j), by inserting ``subject to subsection 
     (o),'' after ``For purposes of this part,''; and
       (2) by adding at the end the following new subsection:
       ``(o) Quality Based Payment Adjustment.--
       ``(1) In general.--In the case of a qualifying plan in a 
     qualifying county with respect to a year beginning with 2011, 
     the blended benchmark amount under subsection (n)(1) shall be 
     increased--
       ``(A) for 2011, by 1.5 percent;
       ``(B) for 2012, by 3.0 percent; and
       ``(C) for a subsequent year, by 5.0 percent.
       ``(2) Qualifying plan and qualifying county defined.--For 
     purposes of this subsection:
       ``(A) Qualifying plan.--The term `qualifying plan' means, 
     for a year and subject to paragraph (4), a plan that, in a 
     preceding year specified by the Secretary, had a quality 
     ranking (based on the quality ranking system established by 
     the Centers for Medicare & Medicaid Services for Medicare 
     Advantage plans) of 4 stars or higher.
       ``(B) Qualifying county.--The term `qualifying county' 
     means, for a year, a county--
       ``(i) that ranked within the lowest third of counties in 
     the amount specified in subsection (n)(2) for a year 
     specified by the Secretary; and
       ``(ii) for which, as of June of a year specified by the 
     Secretary, of the Medicare Advantage eligible individuals 
     residing in the county at least 20 percent of such 
     individuals were enrolled in Medicare Advantage plans.
       ``(3) Determinations of quality.--
       ``(A) Quality performance.--The Secretary shall provide for 
     the computation of a quality performance score for each 
     Medicare Advantage plan to be applied for each year.
       ``(B) Computation of score.--
       ``(i) Quality performance sore.--For years before a year 
     specified by the Secretary, the quality performance score for 
     a Medicare Advantage plan shall be computed based on a blend 
     (as designated by the Secretary) of the plan's performance 
     on--

[[Page 27274]]

       ``(I) HEDIS effectiveness of care quality measures;
       ``(II) CAHPS quality measures; and
       ``(III) such other measures of clinical quality as the 
     Secretary may specify.

     Such measures shall be risk-adjusted as the Secretary deems 
     appropriate.
       ``(ii) Establishment of outcome-based measures.--By not 
     later than for a year specified by the Secretary, the 
     Secretary shall implement reporting requirements for quality 
     under this section on measures selected under clause (iii) 
     that reflect the outcomes of care experienced by individuals 
     enrolled in Medicare Advantage plans (in addition to measures 
     described in clause (i)). Such measures may include--

       ``(I) measures of rates of admission and readmission to a 
     hospital;
       ``(II) measures of prevention quality, such as those 
     established by the Agency for Healthcare Research and Quality 
     (that include hospital admission rates for specified 
     conditions);
       ``(III) measures of patient mortality and morbidity 
     following surgery;
       ``(IV) measures of health functioning (such as limitations 
     on activities of daily living) and survival for patients with 
     chronic diseases;
       ``(V) measures of patient safety; and
       ``(VI) other measure of outcomes and patient quality of 
     life as determined by the Secretary.

     Such measures shall be risk-adjusted as the Secretary deems 
     appropriate. In determining the quality measures to be used 
     under this clause, the Secretary shall take into 
     consideration the recommendations of the Medicare Payment 
     Advisory Commission in its report to Congress under section 
     168 of the Medicare Improvements for Patients and Providers 
     Act of 2008 (Public Law 110-275) and shall provide preference 
     to measures collected on and comparable to measures used in 
     measuring quality under parts A and B.
       ``(iii) Rules for selection of measures.--The Secretary 
     shall select measures for purposes of clause (ii) consistent 
     with the following:

       ``(I) The Secretary shall provide preference to clinical 
     quality measures that have been endorsed by the entity with a 
     contract with the Secretary under section 1890(a).
       ``(II) Prior to any measure being selected under this 
     clause, the Secretary shall publish in the Federal Register 
     such measure and provide for a period of public comment on 
     such measure.

       ``(iv) Transitional use of blend.--For payments for years 
     specified by the Secretary, the Secretary may compute the 
     quality performance score for a Medicare Advantage plan based 
     on a blend of the measures specified in clause (i) and the 
     measures described in clause (ii) and selected under clause 
     (iii).
       ``(v) Use of quality outcomes measures.--For payments 
     beginning with a year specified by the Secretary (beginning 
     after the years specified for section (iv)), the 
     preponderance of measures used under this paragraph shall be 
     quality outcomes measures described in clause (ii) and 
     selected under clause (iii).
       ``(C) Reporting of data.--Each Medicare Advantage 
     organization shall provide for the reporting to the Secretary 
     of quality performance data described in this paragraph (in 
     order to determine a quality performance score under this 
     paragraph) in such time and manner as the Secretary shall 
     specify.
       ``(4) Notification.--The Secretary, in the annual 
     announcement required under subsection (b)(1)(B) in 2010 and 
     each succeeding year, shall notify the Medicare Advantage 
     organization that is offering a qualifying plan in a 
     qualifying county of such identification for the year. The 
     Secretary shall provide for publication on the website for 
     the Medicare program of the information described in the 
     previous sentence.
       ``(5) Authority to disqualify deficient plans.--The 
     Secretary may determine that a Medicare Advantage plan is not 
     a qualifying plan if the Secretary has identified 
     deficiencies in the plan's compliance with rules for Medicare 
     Advantage plans under this part.''.

     SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTENSITY 
                   ADJUSTMENT AUTHORITY.

       Section 1853(a)(1)(C)(ii) of the Social Security Act (42 
     U.S.C. 1395w-23(a)(1)(C)(ii)) is amended--
       (1) in the matter before subclause (I), by striking 
     ``through 2010'' and inserting ``and each subsequent year''; 
     and
       (2) in subclause (II)--
       (A) by inserting ``periodically'' before ``conduct an 
     analysis'';
       (B) by inserting ``on a timely basis'' after ``are 
     incorporated''; and
       (C) by striking ``only for 2008, 2009, and 2010'' and 
     inserting ``for 2008 and subsequent years''.

     SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION 
                   PERIODS.

       (a) 2-Week Processing Period for Annual Enrollment Period 
     (AEP).--Paragraph (3)(B) of section 1851(e) of the Social 
     Security Act (42 U.S.C. 1395w-21(e)) is amended--
       (1) by striking ``and'' at the end of clause (iii);
       (2) in clause (iv)--
       (A) by striking ``and succeeding years'' and inserting ``, 
     2008, 2009, and 2010''; and
       (B) by striking the period at the end and inserting ``; 
     and''; and
       (3) by adding at the end the following new clause:
       ``(v) with respect to 2011 and succeeding years, the period 
     beginning on November 1 and ending on December 15 of the year 
     before such year.''.
       (b) Elimination of 3-Month Additional Open Enrollment 
     Period (OEP).--Effective for plan years beginning with 2011, 
     paragraph (2) of such section is amended by striking 
     subparagraph (C).

     SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS.

       Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C. 
     1395mm(h)(5)(C)) is amended--
       (1) in clause (ii), by striking ``January 1, 2010'' and 
     inserting ``January 1, 2012''; and
       (2) in clause (iii), by striking ``the service area for the 
     year'' and inserting ``the portion of the plan's service area 
     for the year that is within the service area of a reasonable 
     cost reimbursement contract''.

     SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP 
                   PLANS.

       (a) In General.--The first sentence of each of paragraphs 
     (1) and (2) of section 1857(i) of the Social Security Act (42 
     U.S.C. 1395w-27(i)) is amended by inserting before the period 
     at the end the following: ``, but only if 90 percent of the 
     Medicare Advantage eligible individuals enrolled under such 
     plan reside in a county in which the MA organization offers 
     an MA local plan''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply for plan years beginning on or after January 1, 
     2011, and shall not apply to plans which were in effect as of 
     December 31, 2010.

     SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.

       (a) Report to Congress.--Not later than 1 year after the 
     date of the enactment of this Act, the Secretary of Health 
     and Human Services shall submit to Congress a report that 
     evaluates the adequacy of the risk adjustment system under 
     section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 
     1395-23(a)(1)(C)) in predicting costs for beneficiaries with 
     chronic or co-morbid conditions, beneficiaries dually-
     eligible for Medicare and Medicaid, and non-Medicaid eligible 
     low-income beneficiaries; and the need and feasibility of 
     including further gradations of diseases or conditions and 
     multiple years of beneficiary data.
       (b) Improvements to Risk Adjustment.--Not later than 
     January 1, 2012, the Secretary shall implement necessary 
     improvements to the risk adjustment system under section 
     1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395-
     23(a)(1)(C)), taking into account the evaluation under 
     subsection (a).

     SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STABILIZATION 
                   FUND.

       (a) In General.--Section 1858 of the Social Security Act 
     (42 U.S.C. 1395w-27a) is amended by striking subsection (e).
       (b) Transition.--Any amount contained in the MA Regional 
     Plan Stabilization Fund as of the date of the enactment of 
     this Act shall be transferred to the Federal Supplementary 
     Medical Insurance Trust Fund.

     SEC. 1168. STUDY REGARDING THE EFFECTS OF CALCULATING 
                   MEDICARE ADVANTAGE PAYMENT RATES ON A REGIONAL 
                   AVERAGE OF MEDICARE FEE FOR SERVICE RATES.

       (a) In General.--The Administrator of the Centers for 
     Medicare and Medicaid Services shall conduct a study to 
     determine the potential effects of calculating Medicare 
     Advantage payment rates on a more aggregated geographic basis 
     (such as metropolitan statistical areas or other regional 
     delineations) rather than using county boundaries. In 
     conducting such study, the Administrator shall consider the 
     effect of such alternative geographic basis on the following:
       (1) The quality of care received by Medicare Advantage 
     enrollees.
       (2) The networks of Medicare Advantage plans, including any 
     implications for providers contracting with Medicare 
     Advantage plans.
       (3) The predictability of benchmark amounts for Medicare 
     advantage plans.
       (b) Consultations.--In conducting the study, the 
     Administrator shall consult with the following:
       (1) Experts in health care financing.
       (2) Representatives of foundations and other nonprofit 
     entities that have conducted or supported research on 
     Medicare financing issues.
       (3) Representatives from Medicare Advantage plans.
       (4) Such other entities or people as determined by the 
     Secretary.
       (c) Report.--Not later than one year after the date of the 
     enactment of this Act, the Administrator shall transmit a 
     report to the Congress on the study conducted under this 
     section. The report shall contain a detailed statement of 
     findings and conclusions of the study, together with its 
     recommendations for such legislation and administrative 
     actions as the Administrator considers appropriate.

[[Page 27275]]



             PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD

     SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH 
                   SERVICES.

       (a) In General.--Section 1852(a)(1) of the Social Security 
     Act (42 U.S.C. 1395w-22(a)(1)) is amended--
       (1) in subparagraph (A), by inserting before the period at 
     the end the following: ``with cost-sharing that is no greater 
     (and may be less) than the cost-sharing that would otherwise 
     be imposed under such program option'';
       (2) in subparagraph (B)(i), by striking ``or an actuarially 
     equivalent level of cost-sharing as determined in this 
     part''; and
       (3) by amending clause (ii) of subparagraph (B) to read as 
     follows:
       ``(ii) Permitting use of flat copayment or per diem rate.--
     Nothing in clause (i) shall be construed as prohibiting a 
     Medicare Advantage plan from using a flat copayment or per 
     diem rate, in lieu of the cost-sharing that would be imposed 
     under part A or B, so long as the amount of the cost-sharing 
     imposed does not exceed the amount of the cost-sharing that 
     would be imposed under the respective part if the individual 
     were not enrolled in a plan under this part.''.
       (b) Limitation for Dual Eligibles and Qualified Medicare 
     Beneficiaries.--Section 1852(a)(7) of such Act is amended to 
     read as follows:
       ``(7) Limitation on cost-sharing for dual eligibles and 
     qualified medicare beneficiaries.--In the case of a 
     individual who is a full-benefit dual eligible individual (as 
     defined in section 1935(c)(6)) or a qualified medicare 
     beneficiary (as defined in section 1905(p)(1)) who is 
     enrolled in a Medicare Advantage plan, the plan may not 
     impose cost-sharing that exceeds the amount of cost-sharing 
     that would be permitted with respect to the individual under 
     this title and title XIX if the individual were not enrolled 
     with such plan.''.
       (c) Effective Dates.--
       (1) The amendments made by subsection (a) shall apply to 
     plan years beginning on or after January 1, 2011.
       (2) The amendments made by subsection (b) shall apply to 
     plan years beginning on or after January 1, 2011.

     SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS 
                   WITH ENROLLMENT SUSPENSION.

       Section 1851(e)(4) of the Social Security Act (42 U.S.C. 
     1395w(e)(4)) is amended--
       (1) in subparagraph (C), by striking at the end ``or'';
       (2) in subparagraph (D)--
       (A) by inserting ``, taking into account the health or 
     well-being of the individual'' before the period; and
       (B) by redesignating such subparagraph as subparagraph (E); 
     and
       (3) by inserting after subparagraph (C) the following new 
     subparagraph:
       ``(D) the individual is enrolled in an MA plan and 
     enrollment in the plan is suspended under paragraph (2)(B) or 
     (3)(C) of section 1857(g) because of a failure of the plan to 
     meet applicable requirements; or''.

     SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN 
                   ADMINISTRATIVE COSTS.

       (a) Disclosure of Medical Loss Ratios and Other Expense 
     Data.--Section 1851 of the Social Security Act (42 U.S.C. 
     1395w-21), as previously amended by this subtitle, is amended 
     by adding at the end the following new subsection:
       ``(p) Publication of Medical Loss Ratios and Other Cost-
     related Information.--
       ``(1) In general.--The Secretary shall publish, not later 
     than November 1 of each year (beginning with 2011), for each 
     MA plan contract, the medical loss ratio of the plan in the 
     previous year.
       ``(2) Submission of data.--
       ``(A) In general.--Each MA organization shall submit to the 
     Secretary, in a form and manner specified by the Secretary, 
     data necessary for the Secretary to publish the medical loss 
     ratio on a timely basis.
       ``(B) Data for 2010 and 2011.--The data submitted under 
     subparagraph (A) for 2010 and for 2011 shall be consistent in 
     content with the data reported as part of the MA plan bid in 
     June 2009 for 2010.
       ``(C) Use of standardized elements and definitions.--The 
     data to be submitted under subparagraph (A) relating to 
     medical loss ratio for a year, beginning with 2012, shall be 
     submitted based on the standardized elements and definitions 
     developed under paragraph (3).
       ``(3) Development of data reporting standards.--
       ``(A) In general.--The Secretary shall develop and 
     implement standardized data elements and definitions for 
     reporting under this subsection, for contract years beginning 
     with 2012, of data necessary for the calculation of the 
     medical loss ratio for MA plans. Not later than December 31, 
     2010, the Secretary shall publish a report describing the 
     elements and definitions so developed.
       ``(B) Consultation.--The Secretary shall consult with the 
     Health Choices Commissioner, representatives of MA 
     organizations, experts on health plan accounting systems, and 
     representatives of the National Association of Insurance 
     Commissioners, in the development of such data elements and 
     definitions.
       ``(4) Medical loss ratio to be defined.--For purposes of 
     this part, the term `medical loss ratio' has the meaning 
     given such term by the Secretary, taking into account the 
     meaning given such term by the Health Choices Commissioner 
     under section 116 of the Affordable Health Care for America 
     Act.''.
       (b) Minimum Medical Loss Ratio.--Section 1857(e) of the 
     Social Security Act (42 U.S.C. 1395w-27(e)) is amended by 
     adding at the end the following new paragraph:
       ``(4) Requirement for minimum medical loss ratio.--If the 
     Secretary determines for a contract year (beginning with 
     2014) that an MA plan has failed to have a medical loss ratio 
     (as defined in section 1851(p)(4)) of at least .85--
       ``(A) the Secretary shall require the Medicare Advantage 
     organization offering the plan to give enrollees a rebate (in 
     the second succeeding contract year) of premiums under this 
     part (or part B or part D, if applicable) by such amount as 
     would provide for a benefits ratio of at least .85;
       ``(B) for 3 consecutive contract years, the Secretary shall 
     not permit the enrollment of new enrollees under the plan for 
     coverage during the second succeeding contract year; and
       ``(C) the Secretary shall terminate the plan contract if 
     the plan fails to have such a medical loss ratio for 5 
     consecutive contract years.''.

     SEC. 1174. STRENGTHENING AUDIT AUTHORITY.

       (a) For Part C Payments Risk Adjustment.--Section 
     1857(d)(1) of the Social Security Act (42 U.S.C. 1395w-
     27(d)(1)) is amended by inserting after ``section 1858(c))'' 
     the following: ``, and data submitted with respect to risk 
     adjustment under section 1853(a)(3)''.
       (b) Enforcement of Audits and Deficiencies.--
       (1) In general.--Section 1857(e) of such Act, as amended by 
     section 1173, is amended by adding at the end the following 
     new paragraph:
       ``(5) Enforcement of audits and deficiencies.--
       ``(A) Information in contract.--The Secretary shall require 
     that each contract with an MA organization under this section 
     shall include terms that inform the organization of the 
     provisions in subsection (d).
       ``(B) Enforcement authority.--The Secretary is authorized, 
     in connection with conducting audits and other activities 
     under subsection (d), to take such actions, including pursuit 
     of financial recoveries, necessary to address deficiencies 
     identified in such audits or other activities.''.
       (2) Application under part d.--For provision applying the 
     amendment made by paragraph (1) to prescription drug plans 
     under part D, see section 1860D-12(b)(3)(D) of the Social 
     Security Act.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act 
     and shall apply to audits and activities conducted for 
     contract years beginning on or after January 1, 2011.

     SEC. 1175. AUTHORITY TO DENY PLAN BIDS.

       (a) In General.--Section 1854(a)(5) of the Social Security 
     Act (42 U.S.C. 1395w-24(a)(5)) is amended by adding at the 
     end the following new subparagraph:
       ``(C) Rejection of bids.--Nothing in this section shall be 
     construed as requiring the Secretary to accept any or every 
     bid by an MA organization under this subsection.''.
       (b) Application Under Part D.--Section 1860D-11(d) of such 
     Act (42 U.S.C. 1395w-111(d)) is amended by adding at the end 
     the following new paragraph:
       ``(3) Rejection of bids.--Paragraph (5)(C) of section 
     1854(a) shall apply with respect to bids under this section 
     in the same manner as it applies to bids by an MA 
     organization under such section.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to bids for contract years beginning on or after 
     January 1, 2011.

     SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARDIZED MARKETING 
                   REQUIREMENTS.

       Section 1856(b)(3) of the Social Security Act (42 U.S.C. 
     1395w-26(b)(3)) is amended--
       (1) by striking ``The standards'' and inserting ``(A) in 
     general.--The standards'' with appropriate indentation that 
     is the same as for the subparagraph (B) added by paragraph 
     (2); and
       (2) by adding at the end the following new subparagraph:
       ``(B) Enforcement of federal standards permitted.--
       ``(i) In general.--Subject to the subsequent provision of 
     this subparagraph, nothing in this title shall be construed 
     to prohibit a State from conducting a market conduct 
     examination or from imposing civil monetary penalties, in 
     accordance with laws and procedures of the State, against 
     Medicare Advantage organizations, PDP sponsors, or agents or 
     brokers of such organizations or sponsors for violations of 
     the marketing requirements under subsections (h)(4), (h)(6), 
     and (j) of section 1851 and section 1857(g)(1)(E).
       ``(ii) Additional remedies resulting from federal-state 
     cooperation.--

       ``(I) State recommendation.--A State may recommend to the 
     Secretary the imposition of an intermediate sanction not 
     described in clause (i) (such as those available under 
     section 1857(g)) against a Medicare Advantage organization, 
     PDP sponsor, or agent or

[[Page 27276]]

     broker of such an organization or sponsor for a violation 
     described in such clause.
       ``(II) Response to recommendation.--Not later than 30 days 
     after receipt of a recommendation under subclause (I) from a 
     State, with respect to a violation described in clause (i), 
     the Secretary shall respond in writing to the State 
     indicating the progress of any investigation involving such 
     violation, whether the Secretary intends to pursue the 
     recommendation from the State, and in the case the Secretary 
     does not intend to pursue such recommendation, the reason for 
     such decision.

       ``(iii) Non-duplication of penalties.--In the case that an 
     action has been initiated against a Medicare Advantage 
     organization, PDP sponsor, or agent or broker of such an 
     organization or sponsor for a violation of a marketing 
     requirement under subsection (h)(4), (h)(6), or (j) of 
     section 1851 or section 1857(g)(1)(E)--

       ``(I) in the case such action has been initiated by the 
     Secretary, no State may bring an action under such applicable 
     subsection or section against such organization, sponsor, 
     agent, or broker with respect to such violation during the 
     pendency period of the action initiated by the Secretary and, 
     if a penalty is imposed pursuant to such action, after such 
     period; and
       ``(II) in the case such action has been initiated by a 
     State, the Secretary may not bring an action under such 
     applicable subsection or section against such organization, 
     sponsor, agent, or broker with respect to such violation 
     during the pendency period of the action initiated by the 
     Secretary and, if a penalty is imposed pursuant to such 
     action, after such period.

     Nothing in this clause shall be construed as limiting the 
     ability of the Secretary to impose any sanction other than a 
     civil monetary penalty under section 1857 against a Medicare 
     Advantage organization, PDP sponsor, or agent or broker of 
     such an organization or sponsor for a violation described in 
     clause (i).
       ``(iv) Construction.--Nothing in this subparagraph shall be 
     construed as affecting any State authority to regulate 
     brokers described in this paragraph or any other conduct of a 
     Medicare Advantage organization or PDP sponsor.''.

                PART 3--TREATMENT OF SPECIAL NEEDS PLANS

     SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN ENROLLMENT 
                   PERIOD OF INDIVIDUALS INTO CHRONIC CARE 
                   SPECIALIZED MA PLANS FOR SPECIAL NEEDS 
                   INDIVIDUALS.

       Section 1859(f)(4) of the Social Security Act (42 U.S.C. 
     1395w-28(f)(4)) is amended by adding at the end the following 
     new subparagraph:
       ``(C) The plan does not enroll an individual on or after 
     January 1, 2011, other than--
       ``(i) during an annual, coordinated open enrollment period; 
     or
       ``(ii) during a special election period consisting of the 
     period for which the individual has a chronic condition that 
     qualifies the individual as an individual described in 
     subsection (b)(6)(B)(iii) for such plan and ending on the 
     date on which the individual enrolls in such a plan on the 
     basis of such condition.

     If an individual is enrolled in such a plan on the basis of a 
     chronic condition and becomes eligible for another such plan 
     on the basis of another chronic condition, the other plan may 
     enroll the individual on the basis of such other chronic 
     condition during a special enrollment period described in 
     clause (ii). An individual is eligible to apply such clause 
     only once on the basis of any specific chronic condition.''.

     SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO 
                   RESTRICT ENROLLMENT; SERVICE AREA MORATORIUM 
                   FOR CERTAIN SNPS.

       (a) In General.--Section 1859(f)(1) of the Social Security 
     Act (42 U.S.C. 1395w-28(f)(1)) is amended by striking 
     ``January 1, 2011'' and inserting ``January 1, 2013 (or 
     January 1, 2016, in the case of a plan described in section 
     1177(b)(1) of the Affordable Health Care for America Act)''.
       (b) Extension of Certain Plans.--
       (1) Plans described.--For purposes of Section 1859(f)(1) of 
     the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan 
     described in this paragraph is a Medicare Advantage dual 
     eligible special needs plan that--
       (A) whose sponsoring Medicare Advantage organization, as of 
     the date enactment of the Affordable Health Care for America 
     Act, has a contract with a State Medicaid Agency that 
     participated in the ``Demonstrations Serving Those Dually-
     Eligible for Medicare and Medicaid'' under the Medicare 
     program; and
       (B) that has been approved by the Centers for Medicare & 
     Medicaid Services as a dual eligible special needs plan and 
     that offers integrated Medicare and Medicaid services under a 
     contract with the State Medicaid agency.
       (2) Analysis; report.--
       (A) Analysis.--The Secretary of Health and Human Services 
     shall provide, through a contract with an independent health 
     services evaluation organization, for an analysis of the 
     plans described in paragraph (1) with regard to the impact of 
     such plans on cost, quality of care, patient satisfaction, 
     and other subjects specified by the Secretary. Such report 
     also will identify statutory changes needed to simplify 
     access to needed services, improve coordination of benefits 
     and services and ensure protection for dual eligibles as 
     appropriate.
       (B) Report.--Not later than December 31, 2011, the 
     Secretary shall submit to the Congress a report on the 
     analysis under subparagraph (A) and shall include in such 
     report such recommendations with regard to the treatment of 
     such plans as the Secretary deems appropriate.
       (c) Extension of Service Area Moratorium for Certain 
     SNPs.--Section 164(c)(2) of the Medicare Improvements for 
     Patients and Providers Act of 2008 is amended by striking 
     ``December 31, 2010'' and inserting ``December 31, 2012''.

     SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING PLANS.

       Section 1859 of the Social Security Act (42 U.S.C. 1395w-
     28) is amended by adding at the end the following new 
     subsection:
       ``(g) Special Rules for Senior Housing Facility Plans.--
       ``(1) In general.--Notwithstanding any other provision of 
     this part, in the case of a Medicare Advantage senior housing 
     facility plan described in paragraph (2) and for periods 
     before January 1, 2013--
       ``(A) the service area of such plan may be limited to a 
     senior housing facility in a geographic area;
       ``(B) the service area of such plan may not be expanded; 
     and
       ``(C) additional senior housing facilities may not be 
     serviced by such plan.
       ``(2) Medicare advantage senior housing facility plan 
     described.--For purposes of this subsection, a Medicare 
     Advantage senior housing facility plan is a Medicare 
     Advantage plan that--
       ``(A)(i) restricts enrollment of individuals under this 
     part to individuals who reside in a continuing care 
     retirement community (as defined in section 1852(l)(4)(B));
       ``(ii) provides primary care services onsite and has a 
     ratio of accessible providers to beneficiaries that the 
     Secretary determines is adequate, taking into consideration 
     the number of residents onsite, the health needs of those 
     residents, and the accessibility of providers offsite; and
       ``(iii) provides transportation services for beneficiaries 
     to providers outside of the facility; and
       ``(B) is offered by a Medicare Advantage organization that 
     has offered at least 1 plan described in subparagraph (A) for 
     at least 1 year prior to January 1, 2010, under a 
     demonstration project established by the Secretary.''.

              Subtitle E--Improvements to Medicare Part D

     SEC. 1181. ELIMINATION OF COVERAGE GAP.

       (a) Immediate Reduction in Coverage Gap in 2010.--Section 
     1860D-2(b) of the Social Security Act (42 U.S.C. 1395w-
     102(b)) is amended--
       (1) in paragraph (3)(A), by striking ``paragraph (4)'' and 
     inserting ``paragraphs (4) and (7)''; and
       (2) by adding at the end the following new paragraph:
       ``(7) Increase in initial coverage limit in 2010.--
       ``(A) In general.--For plan years beginning during 2010, 
     the initial coverage limit described in paragraph (3)(B) 
     otherwise applicable shall be increased by $500.
       ``(B) Application.--In applying subparagraph (A)--
       ``(i) except as otherwise provided in this subparagraph, 
     there shall be no change in the premiums, bids, or any other 
     parameters under this part or part C;
       ``(ii) costs that would be treated as incurred costs for 
     purposes of applying paragraph (4) but for the application of 
     subparagraph (A) shall continue to be treated as incurred 
     costs;
       ``(iii) the Secretary shall establish procedures, which may 
     include a reconciliation process, to fully reimburse PDP 
     sponsors with respect to prescription drug plans and MA 
     organizations with respect to MA-PD plans for the reduction 
     in beneficiary cost sharing associated with the application 
     of subparagraph (A);
       ``(iv) the Secretary shall develop an estimate of the 
     additional increased costs attributable to the application of 
     this paragraph for increased drug utilization and financing 
     and administrative costs and shall use such estimate to 
     adjust payments to PDP sponsors with respect to prescription 
     drug plans under this part and MA organizations with respect 
     to MA-PD plans under part C; and
       ``(v) the Secretary shall establish procedures for 
     retroactive reimbursement of part D eligible individuals who 
     are covered under such a plan for costs which are incurred 
     before the date of initial implementation of subparagraph (A) 
     and which would be reimbursed under such a plan if such 
     implementation occurred as of January 1, 2010.''.
       (b) Additional Closure in Gap Beginning in 2011.--Section 
     1860D-2(b) of such Act (42 U.S.C. 1395w-102(b)) as amended by 
     subsection (a), is further amended--
       (1) in paragraph (3)(A), by striking ``and (7)'' and 
     inserting ``, (7), and (8)'' ;
       (2) in paragraph (4)(B)(i), by inserting ``subject to 
     paragraph (8)'' after ``purposes of this part''; and

[[Page 27277]]

       (3) by adding at the end the following new paragraph:
       ``(8) Phased-in elimination of coverage gap.--
       ``(A) In general.--For each year beginning with 2011, the 
     Secretary shall consistent with this paragraph progressively 
     increase the initial coverage limit (described in subsection 
     (b)(3)) and decrease the annual out-of-pocket threshold from 
     the amounts otherwise computed until, beginning in 2019, 
     there is a continuation of coverage from the initial coverage 
     limit for expenditures incurred through the total amount of 
     expenditures at which benefits are available under paragraph 
     (4).
       ``(B) Increase in initial coverage limit.--
       ``(i) In general.--For a year beginning with 2011, subject 
     to clause (ii), the initial coverage limit otherwise computed 
     without regard to this paragraph shall be increased by the 
     cumulative ICL phase-in percentage (as defined in clause 
     (iii) for the year) times the out-of-pocket gap amount (as 
     defined in subparagraph (D)) for the year.
       ``(ii) Maintenance of 2010 initial coverage limit level.--
     If for a year the initial coverage limit otherwise computed 
     under this paragraph would be less than the initial coverage 
     limit applied during 2010, taking into account paragraph (7), 
     the initial coverage limit for that year shall be such 
     initial coverage limit as so applied during 2010.
       ``(iii) Cumulative phase-in percentage.--

       ``(I) In general.--For purposes of this paragraph, subject 
     to subclause (II), the term `cumulative ICL phase-in 
     percentage' means for a year the sum of the annual ICL phase-
     in percentage (as defined in clause (iv)) for the year and 
     the annual ICL phase-in percentages for each previous year 
     beginning with 2011.
       ``(II) Limitation.--If the sum of the cumulative ICL phase-
     in percentage and the cumulative OPT phase-in percentage (as 
     defined in subparagraph (C)(iii)) for a year would otherwise 
     exceed 100 percent, each such percentage shall be reduced in 
     a proportional amount so the sum does not exceed 100 percent.

       ``(iv) Annual icl phase-in percentage.--For purposes of 
     this paragraph, the term `annual ICL phase-in percentage' 
     means--

       ``(I) for 2011, 8.25 percent;
       ``(II) for 2012, 2013, and 2014, 4.5 percent;
       ``(III) for 2015 and 2016, 6 percent;
       ``(IV) for 2017, 7.5 percent;
       ``(V) for 2018, 8 percent; and
       ``(VI) for 2019, 8 percent, or such other percent as may be 
     necessary to provide for a full continuation of coverage as 
     described in subparagraph (A) in that year.

       ``(C) Decrease in annual out-of-pocket threshold.--
       ``(i) In general.--For a year beginning with 2011, subject 
     to clause (ii), the annual out-of-pocket threshold otherwise 
     computed without regard to this paragraph shall be decreased 
     by the cumulative OPT phase-in percentage (as defined in 
     clause (iii) for the year) of the out-of-pocket gap amount 
     for the year multiplied by 1.75.
       ``(ii) Maintenance.--The Secretary shall adjust the annual 
     out-of-pocket threshold for a year to the extent necessary to 
     ensure that the sum of the initial coverage limit described 
     in subparagraph (A) and the out-of-pocket gap amount (defined 
     in subparagraph (D)), as determined for the year pursuant to 
     the provisions of this paragraph for such year, does not 
     exceed such sum that would have applied if this paragraph did 
     not apply.
       ``(iii) Cumulative opt phase-in percentage.--For purposes 
     of this paragraph, subject to subparagraph (B)(iii)(II), the 
     term `cumulative OPT phase-in percentage' means for a year 
     the sum of the annual OPT phase-in percentage (as defined in 
     clause (iv)) for the year and the annual OPT phase-in 
     percentages for each previous year beginning with 2011.
       ``(iv) Annual opt phase-in percentage.--For purposes of 
     this paragraph, the term `annual OPT phase-in percentage' 
     means--

       ``(I) for 2011, 0 percent;
       ``(II) for 2012, 2013, and 2014, 4.5 percent;
       ``(III) for 2015 and 2016, 6 percent;
       ``(IV) for 2017, 7.5 percent; and
       ``(V) for 2018 and 2019, 8 percent.

       ``(D) Out-of-pocket gap amount.--For purposes of this 
     paragraph, the term `out-of-pocket gap amount' means for a 
     year the amount by which--
       ``(i) the annual out-of-pocket threshold specified in 
     paragraph (4)(B) for the year (as determined as if this 
     paragraph did not apply), exceeds
       ``(ii) the sum of--

       ``(I) the annual deductible under paragraph (1) for the 
     year; and
       ``(II) \1/4\ of the amount by which the initial coverage 
     limit under paragraph (3) for the year (as determined as if 
     this paragraph did not apply) exceeds such annual deductible.

       ``(E) Relation to aahca transitional increase.--Except as 
     otherwise specifically provided, this paragraph shall be 
     applied as if no increase had been made in the initial 
     coverage limit under paragraph (7).''.
       (c) Requiring Drug Manufacturers to Provide Drug Rebates 
     for Rebate Eligible Individuals.--
       (1) In general.--Section 1860D-2 of the Social Security Act 
     (42 U.S.C. 1395w-102) is amended--
       (A) in subsection (e)(1), in the matter before subparagraph 
     (A), by inserting ``and subsection (f)'' after ``this 
     subsection''; and
       (B) by adding at the end the following new subsection:
       ``(f) Prescription Drug Rebate Agreement for Rebate 
     Eligible Individuals.--
       ``(1) Requirement.--
       ``(A) In general.--For plan years beginning on or after 
     January 1, 2011, in this part, the term `covered part D drug' 
     does not include any drug or biological product that is 
     manufactured by a manufacturer that has not entered into and 
     have in effect a rebate agreement described in paragraph (2).
       ``(B) 2010 plan year requirement.--Any drug or biological 
     product manufactured by a manufacturer that declines to enter 
     into a rebate agreement described in paragraph (2) for the 
     period beginning on January 1, 2010, and ending on December 
     31, 2010, shall not be included as a `covered part D drug ` 
     for the subsequent plan year.
       ``(2) Rebate agreement.--A rebate agreement under this 
     subsection shall require the manufacturer to provide to the 
     Secretary a rebate for each rebate period (as defined in 
     paragraph (6)(B)) ending after December 31, 2009, in the 
     amount specified in paragraph (3) for any covered part D drug 
     of the manufacturer dispensed after December 31, 2009, to any 
     rebate eligible individual (as defined in paragraph (6)(A)) 
     for which payment was made by a PDP sponsor under part D or a 
     MA organization under part C for such period, including 
     payments passed through the low-income and reinsurance 
     subsidies under sections 1860D-14 and 1860D-15(b), 
     respectively. Such rebate shall be paid by the manufacturer 
     to the Secretary not later than 30 days after the date of 
     receipt of the information described in section 1860D-
     12(b)(7), including as such section is applied under section 
     1857(f)(3), or 30 days after the receipt of information under 
     subparagraph (D) of paragraph (3), as determined by the 
     Secretary. Insofar as not inconsistent with this subsection, 
     the Secretary shall establish terms and conditions of such 
     agreement relating to compliance, penalties, and program 
     evaluations, investigations, and audits that are similar to 
     the terms and conditions for rebate agreements under 
     paragraphs (3) and (4) of section 1927(b).
       ``(3) Rebate for rebate eligible medicare drug plan 
     enrollees.--
       ``(A) In general.--The amount of the rebate specified under 
     this paragraph for a manufacturer for a rebate period, with 
     respect to each dosage form and strength of any covered part 
     D drug provided by such manufacturer and dispensed to a 
     rebate eligible individual, shall be equal to the product 
     of--
       ``(i) the total number of units of such dosage form and 
     strength of the drug so provided and dispensed for which 
     payment was made by a PDP sponsor under part D or a MA 
     organization under part C for the rebate period, including 
     payments passed through the low-income and reinsurance 
     subsidies under sections 1860D-14 and 1860D-15(b), 
     respectively; and
       ``(ii) the amount (if any) by which--

       ``(I) the Medicaid rebate amount (as defined in 
     subparagraph (B)) for such form, strength, and period, 
     exceeds
       ``(II) the average Medicare drug program rebate eligible 
     rebate amount (as defined in subparagraph (C)) for such form, 
     strength, and period.

       ``(B) Medicaid rebate amount.--For purposes of this 
     paragraph, the term `Medicaid rebate amount' means, with 
     respect to each dosage form and strength of a covered part D 
     drug provided by the manufacturer for a rebate period--
       ``(i) in the case of a single source drug or an innovator 
     multiple source drug, the amount specified in paragraph 
     (1)(A)(ii) of section 1927(c) plus the amount, if any, 
     specified in paragraph (2)(A)(ii) of such section, for such 
     form, strength, and period; or
       ``(ii) in the case of any other covered outpatient drug, 
     the amount specified in paragraph (3)(A)(i) of such section 
     for such form, strength, and period.
       ``(C) Average medicare drug program rebate eligible rebate 
     amount.--For purposes of this subsection, the term `average 
     Medicare drug program rebate eligible rebate amount' means, 
     with respect to each dosage form and strength of a covered 
     part D drug provided by a manufacturer for a rebate period, 
     the sum, for all PDP sponsors under part D and MA 
     organizations administering a MA-PD plan under part C, of--
       ``(i) the product, for each such sponsor or organization, 
     of--

       ``(I) the sum of all rebates, discounts, or other price 
     concessions (not taking into account any rebate provided 
     under paragraph (2) for such dosage form and strength of the 
     drug dispensed, calculated on a per-unit basis, but only to 
     the extent that any such rebate, discount, or other price 
     concession applies equally to drugs dispensed to rebate 
     eligible Medicare drug plan enrollees and drugs dispensed to 
     PDP and MA-PD enrollees who are not rebate eligible 
     individuals; and
       ``(II) the number of the units of such dosage and strength 
     of the drug dispensed during the rebate period to rebate 
     eligible individuals enrolled in the prescription drug plans 
     administered by the PDP sponsor or the MA-PD plans 
     administered by the MA organization; divided by

[[Page 27278]]

       ``(ii) the total number of units of such dosage and 
     strength of the drug dispensed during the rebate period to 
     rebate eligible individuals enrolled in all prescription drug 
     plans administered by PDP sponsors and all MA-PD plans 
     administered by MA organizations.
       ``(D) Use of estimates.--The Secretary may establish a 
     methodology for estimating the average Medicare drug program 
     rebate eligible rebate amounts for each rebate period based 
     on bid and utilization information under this part and may 
     use these estimates as the basis for determining the rebates 
     under this section. If the Secretary elects to estimate the 
     average Medicare drug program rebate eligible rebate amounts, 
     the Secretary shall establish a reconciliation process for 
     adjusting manufacturer rebate payments not later than 3 
     months after the date that manufacturers receive the 
     information collected under section 1860D-12(b)(7)(B).
       ``(4) Length of agreement.--The provisions of paragraph (4) 
     of section 1927(b) (other than clauses (iv) and (v) of 
     subparagraph (B)) shall apply to rebate agreements under this 
     subsection in the same manner as such paragraph applies to a 
     rebate agreement under such section.
       ``(5) Other terms and conditions.--The Secretary shall 
     establish other terms and conditions of the rebate agreement 
     under this subsection, including terms and conditions related 
     to compliance, that are consistent with this subsection.
       ``(6) Definitions.--In this subsection and section 1860D-
     12(b)(7):
       ``(A) Rebate eligible individual.--The term `rebate 
     eligible individual'--
       ``(i) means a full-benefit dual eligible individual (as 
     defined in section 1935(c)(6)); and
       ``(ii) includes, for drugs dispensed after December 31, 
     2014, a subsidy eligible individual (as defined in section 
     1860D-14(a)(3)(A)).
       ``(B) Rebate period.--The term `rebate period' has the 
     meaning given such term in section 1927(k)(8).
       ``(7) Waiver.--Chapter 35 of title 44, United States Code, 
     shall not apply to the requirements under this subsection for 
     the period beginning on January 1, 2010, and ending on 
     December 31, 2010.''.
       (2) Reporting requirement for the determination and payment 
     of rebates by manufactures related to rebate for rebate 
     eligible medicare drug plan enrollees.--
       (A) Requirements for pdp sponsors.--Section 1860D-12(b) of 
     the Social Security Act (42 U.S.C. 1395w-112(b)) is amended 
     by adding at the end the following new paragraph:
       ``(7) Reporting requirement for the determination and 
     payment of rebates by manufacturers related to rebate for 
     rebate eligible medicare drug plan enrollees.--
       ``(A) In general.--For purposes of the rebate under section 
     1860D-2(f) for contract years beginning on or after January 
     1, 2011, each contract entered into with a PDP sponsor under 
     this part with respect to a prescription drug plan shall 
     require that the sponsor comply with subparagraphs (B) and 
     (C).
       ``(B) Report form and contents.--Not later than a date 
     specified by the Secretary, a PDP sponsor of a prescription 
     drug plan under this part shall report to each manufacturer--
       ``(i) information (by National Drug Code number) on the 
     total number of units of each dosage, form, and strength of 
     each drug of such manufacturer dispensed to rebate eligible 
     Medicare drug plan enrollees under any prescription drug plan 
     operated by the PDP sponsor during the rebate period;
       ``(ii) information on the price discounts, price 
     concessions, and rebates for such drugs for such form, 
     strength, and period;
       ``(iii) information on the extent to which such price 
     discounts, price concessions, and rebates apply equally to 
     rebate eligible Medicare drug plan enrollees and PDP 
     enrollees who are not rebate eligible Medicare drug plan 
     enrollees; and
       ``(iv) any additional information that the Secretary 
     determines is necessary to enable the Secretary to calculate 
     the average Medicare drug program rebate eligible rebate 
     amount (as defined in paragraph (3)(C) of such section), and 
     to determine the amount of the rebate required under this 
     section, for such form, strength, and period.

     Such report shall be in a form consistent with a standard 
     reporting format established by the Secretary.
       ``(C) Submission to secretary.--Each PDP sponsor shall 
     promptly transmit a copy of the information reported under 
     subparagraph (B) to the Secretary for the purpose of audit 
     oversight and evaluation.
       ``(D) Confidentiality of information.--The provisions of 
     subparagraph (D) of section 1927(b)(3), relating to 
     confidentiality of information, shall apply to information 
     reported by PDP sponsors under this paragraph in the same 
     manner that such provisions apply to information disclosed by 
     manufacturers or wholesalers under such section, except--
       ``(i) that any reference to `this section' in clause (i) of 
     such subparagraph shall be treated as being a reference to 
     this section;
       ``(ii) the reference to the Director of the Congressional 
     Budget Office in clause (iii) of such subparagraph shall be 
     treated as including a reference to the Medicare Payment 
     Advisory Commission; and
       ``(iii) clause (iv) of such subparagraph shall not apply.
       ``(E) Oversight.--Information reported under this paragraph 
     may be used by the Inspector General of the Department of 
     Health and Human Services for the statutorily authorized 
     purposes of audit, investigation, and evaluations.
       ``(F) Penalties for failure to provide timely information 
     and provision of false information.--In the case of a PDP 
     sponsor--
       ``(i) that fails to provide information required under 
     subparagraph (B) on a timely basis, the sponsor is subject to 
     a civil money penalty in the amount of $10,000 for each day 
     in which such information has not been provided; or
       ``(ii) that knowingly (as defined in section 1128A(i)) 
     provides false information under such subparagraph, the 
     sponsor is subject to a civil money penalty in an amount not 
     to exceed $100,000 for each item of false information.

     Such civil money penalties are in addition to other penalties 
     as may be prescribed by law. The provisions of section 1128A 
     (other than subsections (a) and (b)) shall apply to a civil 
     money penalty under this subparagraph in the same manner as 
     such provisions apply to a penalty or proceeding under 
     section 1128A(a).''.
       (B) Application to ma organizations.--Section 1857(f)(3) of 
     the Social Security Act (42 U.S.C. 1395w-27(f)(3)) is amended 
     by adding at the end the following:
       ``(D) Reporting requirement related to rebate for rebate 
     eligible medicare drug plan enrollees.--Section 1860D-
     12(b)(7).''.
       (3) Deposit of rebates into medicare prescription drug 
     account.--Section 1860D-16(c) of such Act (42 U.S.C. 1395w-
     116(c)) is amended by adding at the end the following new 
     paragraph:
       ``(6) Rebate for rebate eligible medicare drug plan 
     enrollees.--Amounts paid under a rebate agreement under 
     section 1860D-2(f) shall be deposited into the Account and 
     shall be used to pay for all or part of the gradual 
     elimination of the coverage gap under section 1860D-
     2(b)(7).''.

     SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL 
                   COVERAGE GAP.

       Section 1860D-2 of the Social Security Act (42 U.S.C. 
     1395w-102), as amended by section 1181, is amended--
       (1) in subsection (b)(4)(C)(ii), by inserting ``subject to 
     subsection (g)(2)(C),'' after ``(ii)'';
       (2) in subsection (e)(1), in the matter before subparagraph 
     (A), by striking ``subsection (f)'' and inserting 
     ``subsections (f) and (g)'' after ``this subsection''; and
       (3) by adding at the end the following new subsection:
       ``(g) Requirement for Manufacturer Discount Agreement for 
     Certain Qualifying Drugs.--
       ``(1) In general.--In this part, the term `covered part D 
     drug' does not include any drug or biological product that is 
     manufactured by a manufacturer that has not entered into and 
     have in effect for all qualifying drugs (as defined in 
     paragraph (5)(A)) a discount agreement described in paragraph 
     (2).
       ``(2) Discount agreement.--
       ``(A) Periodic discounts.--A discount agreement under this 
     paragraph shall require the manufacturer involved to provide, 
     to each PDP sponsor with respect to a prescription drug plan 
     or each MA organization with respect to each MA-PD plan, a 
     discount in an amount specified in paragraph (3) for 
     qualifying drugs (as defined in paragraph (5)(A)) of the 
     manufacturer dispensed to a qualifying enrollee after January 
     1, 2010, insofar as the individual is in the original gap in 
     coverage (as defined in paragraph (5)(E)).
       ``(B) Discount agreement.--Insofar as not inconsistent with 
     this subsection, the Secretary shall establish terms and 
     conditions of such agreement, including terms and conditions 
     relating to compliance, similar to the terms and conditions 
     for rebate agreements under paragraphs (2), (3), and (4) of 
     section 1927(b), except that--
       ``(i) discounts shall be applied under this subsection to 
     prescription drug plans and MA-PD plans instead of State 
     plans under title XIX;
       ``(ii) PDP sponsors and MA organizations shall be 
     responsible, instead of States, for provision of necessary 
     utilization information to drug manufacturers; and
       ``(iii) sponsors and MA organizations shall be responsible 
     for reporting information on drug-component negotiated price.
       ``(C) Counting discount toward true out-of-pocket costs.--
     Under the discount agreement, in applying subsection (b)(4), 
     with regard to subparagraph (C)(i) of such subsection, if a 
     qualified enrollee purchases the qualified drug insofar as 
     the enrollee is in an actual gap of coverage (as defined in 
     paragraph (5)(D)), the amount of the discount under the 
     agreement shall be treated and counted as costs incurred by 
     the plan enrollee.
       ``(3) Discount amount.--The amount of the discount 
     specified in this paragraph for a discount period for a plan 
     is equal to 50 percent of the amount of the drug-component 
     negotiated price (as defined in paragraph (5)(C)) for 
     qualifying drugs for the period involved.

[[Page 27279]]

       ``(4) Additional terms.--In the case of a discount provided 
     under this subsection with respect to a prescription drug 
     plan offered by a PDP sponsor or an MA-PD plan offered by an 
     MA organization, if a qualified enrollee purchases the 
     qualified drug--
       ``(A) insofar as the enrollee is in an actual gap of 
     coverage (as defined in paragraph (5)(D)), the sponsor or 
     plan shall provide the discount to the enrollee at the time 
     the enrollee pays for the drug; and
       ``(B) insofar as the enrollee is in the portion of the 
     original gap in coverage (as defined in paragraph (5)(E)) 
     that is not in the actual gap in coverage, the discount shall 
     not be applied against the negotiated price (as defined in 
     subsection (d)(1)(B)) for the purpose of calculating the 
     beneficiary payment.
       ``(5) Definitions.--In this subsection:
       ``(A) Qualifying drug.--The term `qualifying drug' means, 
     with respect to a prescription drug plan or MA-PD plan, a 
     drug or biological product that--
       ``(i)(I) is a drug produced or distributed under an 
     original new drug application approved by the Food and Drug 
     Administration, including a drug product marketed by any 
     cross-licensed producers or distributors operating under the 
     new drug application;
       ``(II) is a drug that was originally marketed under an 
     original new drug application approved by the Food and Drug 
     Administration; or
       ``(III) is a biological product as approved under Section 
     351(a) of the Public Health Services Act;
       ``(ii) is covered under the formulary of the plan or is 
     treated as covered under the formulary of the plan as a 
     result of a coverage determination or appeal under subsection 
     (g) or (h) of section 1860D-4; and
       ``(iii) is dispensed to an individual who is in the 
     original gap in coverage.
       ``(B) Qualifying enrollee.--The term `qualifying enrollee' 
     means an individual enrolled in a prescription drug plan or 
     MA-PD plan other than such an individual who is a subsidy-
     eligible individual (as defined in section 1860D-14(a)(3)).
       ``(C) Drug-component negotiated price.--The term `drug-
     component negotiated price' means, with respect to a 
     qualifying drug, the negotiated price (as defined in section 
     423.100 of title 42, Code of Federal Regulations, as in 
     effect on the date of enactment of this subsection), as 
     determined without regard to any dispensing fee, of the drug 
     under the prescription drug plan or MA-PD plan involved.
       ``(D) Actual gap in coverage.--The term `actual gap in 
     coverage' means the gap in prescription drug coverage that 
     occurs between the initial coverage limit (as modified under 
     paragraph (7) and subparagraph (B) of paragraph (8) of 
     subsection (b)) and the annual out-of-pocket threshold (as 
     modified under subparagraph (C) of such subsection).
       ``(E) Original gap in coverage.--The term `original in gap 
     coverage' means the gap in prescription drug coverage that 
     would occur between the initial coverage limit (described in 
     subsection (b)(3)) and the out-of-pocket threshold (as 
     defined in subsection (b)(4)(B)) if subsections (b)(7) and 
     (b)(8) did not apply.
       ``(6) Special rule for 2010.--For the period beginning 
     January 1, 2010, and ending December 31, 2010, the Secretary 
     may--
       ``(A) enter into agreements with manufacturers to directly 
     receive the discount amount described in paragraph (3);
       ``(B) collect the necessary information from prescription 
     drug plans and MA-PD plans to calculate the discount amount 
     described in such paragraph; and
       ``(C) provide the discount described in such paragraph to 
     beneficiaries as close as practicable after the point of 
     sale.
       ``(7) Waiver.--Chapter 35 of title 44, United States Code, 
     shall not apply to the requirements under this subsection for 
     the period beginning on January 1, 2010, and ending on 
     December 31, 2010.''.

     SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF 
                   CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING 
                   WITH LONG-TERM CARE FACILITIES.

       (a) Part D Submission.--Section 1860D-12(b) of the Social 
     Security Act (42 U.S.C. 1395w-112(b)), as amended by section 
     172(a)(1) of Public Law 110-275, is amended by striking 
     paragraph (5) and redesignating paragraph (6) and paragraph 
     (7), as added by section 1181(c)(2)(A), as paragraph (5) and 
     paragraph (6), respectively.
       (b) Submission to MA-PD Plans.--Section 1857(f)(3) of the 
     Social Security Act (42 U.S.C. 1395w-27(f)(3)), as added by 
     section 171(b) of Public Law 110-275 and amended by section 
     172(a)(2) of such Public Law and section 1181 of this Act, is 
     amended by striking subparagraph (B) and redesignating 
     subparagraphs (C) and (D) as subparagraphs (B) and (C) 
     respectively.
       (c) Effective Date.--The amendments made by this section 
     shall apply for contract years beginning with 2010.

     SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE 
                   PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING 
                   PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF-
                   POCKET THRESHOLD UNDER PART D.

       (a) In General.--Section 1860D-2(b)(4)(C) of the Social 
     Security Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) in clause (ii)--
       (A) by striking ``such costs shall be treated as incurred 
     only if'' and inserting ``and subject to clause (iii), such 
     costs shall be treated as incurred only if'';
       (B) by striking ``, under section 1860D-14, or under a 
     State Pharmaceutical Assistance Program''; and
       (C) by striking the period at the end and inserting ``; 
     and''; and
       (3) by inserting after clause (ii) the following new 
     clause:
       ``(iii) such costs shall be treated as incurred and shall 
     not be considered to be reimbursed under clause (ii) if such 
     costs are borne or paid--

       ``(I) under section 1860D-14;
       ``(II) under a State Pharmaceutical Assistance Program;
       ``(III) by the Indian Health Service, an Indian tribe or 
     tribal organization, or an urban Indian organization (as 
     defined in section 4 of the Indian Health Care Improvement 
     Act); or
       ``(IV) under an AIDS Drug Assistance Program under part B 
     of title XXVI of the Public Health Service Act.''.

       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to costs incurred on or after January 1, 2011.

     SEC. 1185. NO MID-YEAR FORMULARY CHANGES PERMITTED.

       (a) In General.--Section 1860D-4(b)(3)(E) of the Social 
     Security Act (42 U.S.C. 1395w-104(b)(3)(E)) is amended--
       (1) in the heading, by inserting ``; certain formulary 
     changes only before initiating marketing for a plan year'' 
     after ``status of drug'';
       (2) by striking ``Any removal'' and inserting ``(i) 
     notice.--Any removal'' with the same indentation as the 
     clause added by paragraph (2);
       (3) by adding at the end the following new clause:
       ``(ii) Certain changes in formulary only before initiating 
     marketing for a plan year.--Any removal of a covered part D 
     drug from a formulary used by a PDP sponsor of a prescription 
     drug plan (or MA organization of a MA-PD plan) or any other 
     material change to the formulary so as to reduce the coverage 
     (or increase the cost-sharing) of the drug under the plan for 
     a plan year shall take effect by a date specified by the 
     Secretary but no later than the start of plan marketing 
     activities for the plan year. In addition to any exceptions 
     to the previous sentence specified by the Secretary, the 
     previous sentence shall not apply in the case that a drug is 
     removed from the formulary of a plan because of a recall or 
     withdrawal of the drug issued by the Food and Drug 
     Administration, because the drug is replaced with a generic 
     drug that is a therapeutic equivalent, or because of 
     utilization management applied to--

       ``(I) a drug whose labeling includes a boxed warning 
     required by the Food and Drug Administration under section 
     201.57(c)(1) of title 21, Code of Federal Regulations (or a 
     successor regulation); or
       ``(II) a drug required under subsection (c)(2) of section 
     505-1 of the Federal Food, Drug, and Cosmetic Act to have a 
     Risk Evaluation and Management Strategy that includes 
     elements under subsection (f) of such section.''.

       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to contract years beginning on or after January 
     1, 2011.

     SEC. 1186. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON 
                   BEHALF OF MEDICARE BENEFICIARIES.

       (a) Negotiation by Secretary.--Section 1860D-11 of the 
     Social Security Act (42 U.S.C. 1395w-111) is amended by 
     striking subsection (i) (relating to noninterference) and 
     inserting the following:
       ``(i) Negotiation of Lower Drug Prices.--
       ``(1) In general.--Notwithstanding any other provision of 
     law, the Secretary shall negotiate with pharmaceutical 
     manufacturers the prices (including discounts, rebates, and 
     other price concessions) that may be charged to PDP sponsors 
     and MA organizations for covered part D drugs for part D 
     eligible individuals who are enrolled under a prescription 
     drug plan or under an MA-PD plan.
       ``(2) No change in rules for formularies.--
       ``(A) In general.--Nothing in paragraph (1) shall be 
     construed to authorize the Secretary to establish or require 
     a particular formulary.
       ``(B) Construction.--Subparagraph (A) shall not be 
     construed as affecting the Secretary's authority to ensure 
     appropriate and adequate access to covered part D drugs under 
     prescription drug plans and under MA-PD plans, including 
     compliance of such plans with formulary requirements under 
     section 1860D-4(b)(3).
       ``(3) Construction.--Nothing in this subsection shall be 
     construed as preventing the sponsor of a prescription drug 
     plan, or an organization offering an MA-PD plan, from 
     obtaining a discount or reduction of the price for a covered 
     part D drug below the price negotiated under paragraph (1).
       ``(4) Annual reports to congress.--Not later than June 1, 
     2011, and annually thereafter, the Secretary shall submit to 
     the Committees on Ways and Means, Energy and

[[Page 27280]]

     Commerce, and Oversight and Government Reform of the House of 
     Representatives and the Committee on Finance of the Senate a 
     report on negotiations conducted by the Secretary to achieve 
     lower prices for Medicare beneficiaries, and the prices and 
     price discounts achieved by the Secretary as a result of such 
     negotiations.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on the date of the enactment of this Act 
     and shall first apply to negotiations and prices for plan 
     years beginning on January 1, 2011.

     SEC. 1187. ACCURATE DISPENSING IN LONG-TERM CARE FACILITIES.

       Section 1860D-4(c) of the Social Security Act (42 U.S.C. 
     1395w-104(c)) is amended by adding at the end the following 
     new paragraph:
       ``(3) Reduction of wasteful dispensing.--
       ``(A) In general.--For plan years beginning on or after 
     January 1, 2012, a PDP sponsor offering a prescription drug 
     plan and MA organization offering a MA-PD plan under part C 
     shall have in place the utilization management techniques 
     established under subparagraph (B).
       ``(B) Requirements.--The Secretary shall establish 
     utilization management techniques, such as daily, weekly, or 
     automated dose dispensing, to apply to PDP sponsors and MA 
     organizations to reduce the quantities of covered part D 
     drugs dispensed to enrollees who are residing in long-term 
     care facilities in order to reduce waste associated with 
     unused medications.
       ``(C) Consultation.--In establishing the requirements under 
     subparagraph (A), the Secretary shall consult with the 
     Administrator of the Environmental Protection Agency, 
     Administrator of the Food and Drug Administration, 
     Administrator of the Drug Enforcement Administration, State 
     Boards of Pharmacy, pharmacy and physician organizations, and 
     other appropriate stakeholders to study and determine 
     additional methods for prescription drug plans to reduce 
     waste associated with unused prescription drugs.''.

     SEC. 1188. FREE GENERIC FILL.

       (a) In General.--Section 1128A(i)(6) of the Social Security 
     Act (42 U.S.C. 1320a-7a(i)(6)) is amended--
       (1) in subparagraph (C), by striking ``of 1996'' and all 
     that follows and inserting ``of 1996;'';
       (2) in the first subparagraph (D), by striking 
     ``promulgated'' and all that follows and inserting 
     ``promulgated;'';
       (3) by redesignating the second subparagraph (D) as a 
     subparagraph (E) and by striking the period at the end of 
     such subparagraph and inserting ``; and''; and
       (4) by adding at the end the following new subparagraph:
       ``(F) with regard to a prescription drug plan offered by a 
     PDP sponsor or an MA-PD plan offered by an MA organization, a 
     reduction in or waiver of the copayment amount under the plan 
     given to an individual to induce the individual to switch to 
     a generic, bioequivalent drug, or biosimilar.''.
       (b) Effective Date.--The amendments made by this subsection 
     shall take effect on the date of the enactment of this Act 
     and shall first apply with respect to remuneration offered, 
     paid, solicited, or received on or after January 1, 2011.

     SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LICENSURE 
                   REQUIREMENTS UNDER MEDICARE PRESCRIPTION DRUG 
                   PROGRAM.

       (a) In General.--Section 1860D-12(c) of the Social Security 
     Act (42 U.S.C. 1395w-112(c)) is amended--
       (1) in paragraph (1)(A), by striking ``In the case'' and 
     inserting ``Subject to paragraph (5), in the case''; and
       (2) by adding at the end the following new paragraph:
       ``(5) State certification required.--
       ``(A) In general.--Except as provided in section 1860D-
     21(f)(4), the Secretary may only grant a waiver under 
     paragraph (1)(A) if the Secretary has received a 
     certification from the State insurance commissioner that the 
     prescription drug plan has a substantially complete 
     application pending in the State.
       ``(B) Revocation of waiver upon finding of fraud and 
     abuse.--The Secretary shall revoke a waiver granted under 
     paragraph (1)(A) if the State insurance commissioner submits 
     a certification to the Secretary that the recipient of such a 
     waiver--
       ``(i) has committed fraud or abuse with respect to such 
     waiver;
       ``(ii) has failed to make a good faith effort to satisfy 
     State licensing requirements; or
       ``(iii) was determined ineligible for licensure by the 
     State.''.
       (b) Exception for PACE Programs.--Section 1860D-21(f) of 
     such Act (42 U.S.C. 1395w-131(f)) is amended--
       (1) in paragraph (1), by striking ``paragraphs (2) and 
     (3)'' and inserting ``the succeeding paragraphs''; and
       (2) by adding at the end the following new paragraph:
       ``(4) Inapplicability of certain licensure waiver 
     requirements.--The provisions of paragraph (1) of section 
     1860D-12(c) (relating to waiver of licensure under certain 
     circumstances) shall apply without regard to paragraph (5) of 
     such section in the case of a PACE program that elects to 
     provide qualified prescription drug coverage to a part D 
     eligible individual who is enrolled under such program.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply with respect to plan years beginning on or after 
     January 1, 2010.

             Subtitle F--Medicare Rural Access Protections

     SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.

       (a) Additional Telehealth Site.--
       (1) In general.--Paragraph (4)(C)(ii) of section 1834(m) of 
     the Social Security Act (42 U.S.C. 1395m(m)) is amended by 
     adding at the end the following new subclause:

       ``(IX) A renal dialysis facility.''

       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to services furnished on or after January 1, 
     2011.
       (b) Telehealth Advisory Committee.--
       (1) Establishment.--Section 1868 of the Social Security Act 
     (42 U.S.C. 1395ee) is amended--
       (A) in the heading, by adding at the end the following: 
     ``telehealth advisory committee''; and
       (B) by adding at the end the following new subsection:
       ``(c) Telehealth Advisory Committee.--
       ``(1) In general.--The Secretary shall appoint a Telehealth 
     Advisory Committee (in this subsection referred to as the 
     `Advisory Committee') to make recommendations to the 
     Secretary on policies of the Centers for Medicare & Medicaid 
     Services regarding telehealth services as established under 
     section 1834(m), including the appropriate addition or 
     deletion of services (and HCPCS codes) to those specified in 
     paragraphs (4)(F)(i) and (4)(F)(ii) of such section and for 
     authorized payment under paragraph (1) of such section.
       ``(2) Membership; terms.--
       ``(A) Membership.--
       ``(i) In general.--The Advisory Committee shall be composed 
     of 9 members, to be appointed by the Secretary, of whom--

       ``(I) 5 shall be practicing physicians;
       ``(II) 2 shall be practicing non-physician health care 
     practitioners; and
       ``(III) 2 shall be administrators of telehealth programs.

       ``(ii) Requirements for appointing members.--In appointing 
     members of the Advisory Committee, the Secretary shall--

       ``(I) ensure that each member has prior experience with the 
     practice of telemedicine or telehealth;
       ``(II) give preference to individuals who are currently 
     providing telemedicine or telehealth services or who are 
     involved in telemedicine or telehealth programs;
       ``(III) ensure that the membership of the Advisory 
     Committee represents a balance of specialties and geographic 
     regions; and
       ``(IV) take into account the recommendations of 
     stakeholders.

       ``(B) Terms.--The members of the Advisory Committee shall 
     serve for such term as the Secretary may specify.
       ``(C) Conflicts of interest.--An advisory committee member 
     may not participate with respect to a particular matter 
     considered in an advisory committee meeting if such member 
     (or an immediate family member of such member) has a 
     financial interest that could be affected by the advice given 
     to the Secretary with respect to such matter.
       ``(3) Meetings.--The Advisory Committee shall meet twice 
     each calendar year and at such other times as the Secretary 
     may provide.
       ``(4) Permanent committee.--Section 14 of the Federal 
     Advisory Committee Act (5 U.S.C. App.) shall not apply to the 
     Advisory Committee.''
       (2) Following recommendations.--Section 1834(m)(4)(F) of 
     such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at 
     the end the following new clause:
       ``(iii) Recommendations of the telehealth advisory 
     committee.--In making determinations under clauses (i) and 
     (ii), the Secretary shall take into account the 
     recommendations of the Telehealth Advisory Committee 
     (established under section 1868(c)) when adding or deleting 
     services (and HCPCS codes) and in establishing policies of 
     the Centers for Medicare & Medicaid Services regarding the 
     delivery of telehealth services. If the Secretary does not 
     implement such a recommendation, the Secretary shall publish 
     in the Federal Register a statement regarding the reason such 
     recommendation was not implemented.''
       (3) Waiver of administrative limitation.--The Secretary of 
     Health and Human Services shall establish the Telehealth 
     Advisory Committee under the amendment made by paragraph (1) 
     notwithstanding any limitation that may apply to the number 
     of advisory committees that may be established (within the 
     Department of Health and Human Services or otherwise).
       (c) Hospital Credentialing of Telemedicine Physicians and 
     Practitioners.--
       (1) In general.--Not later than 60 days after the date of 
     the enactment of this Act, the Secretary of Health and Human 
     Services shall issue guidance for hospitals (as defined in 
     paragraph (4)) to simplify requirements regarding compiling 
     practitioner credentials for the purpose of rendering a 
     medical staff privileging decision (under bylaws of the

[[Page 27281]]

     type described in section 1861(e)(3) of the Social Security 
     Act) for physicians and practitioners (as defined in 
     paragraph (4)) delivering telehealth services that are 
     furnished via a telecommunications system.
       (2) Flexibility in accepting credentialing by another 
     medicare participating hospital.--
       (A) In general.--Such guidance shall permit a hospital to 
     accept credentialing packages compiled by another hospital 
     participating under Medicare with regard to physicians and 
     practitioners who seek medical staff privileges in the 
     hospital to provide telehealth services via a 
     telecommunications system from a site other than the hospital 
     where the patient is located.
       (B) Construction.--Nothing in this subsection shall be 
     construed to require a hospital to accept the credentialing 
     package compiled by another facility.
       (C) No oversight required.--If a hospital does accept the 
     credentialing materials prepared by another hospital, the 
     hospital shall not be required to exercise oversight over the 
     other hospital's process for compiling and verifying 
     credentials.  
       (D) Privileging.--This paragraph shall only apply to 
     credentialing and does not relieve a hospital from any 
     applicable privileging requirements.
       (3) Construction.--This subsection shall not be construed 
     as limiting the ability of the Secretary to issue additional 
     guidance regarding the requirements for the compilation of 
     credentials for physicians and practitioners not described in 
     paragraph (1).
       (4) Definitions.--In this subsection:
       (A) The term ``hospital'' has the meaning given such term 
     in subsection (e) of section 1861 of the Social Security Act 
     (42 U.S.C. 1395x) and includes a critical access hospital (as 
     defined in subsection (mm)(1) of such section).
       (B) The term ``physician'' has the meaning given such term 
     in subsection (r) of such section.
       (C) The term ``practitioner'' means a practitioner 
     described in section 1842(b)(18)(C) of the Social Security 
     Act (42 U.S.C. 1395u(b)(18)(C)).

     SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

        Section 1833(t)(7)(D)(i) of the Social Security Act (42 
     U.S.C. 1395l(t)(7)(D)(i)) is amended--
       (1) in subclause (II)--
       (A) in the first sentence, by striking ```2010'' and 
     inserting ``2012''; and
       (B) in the second sentence, by striking ``or 2009'' and 
     inserting ``, 2009, 2010, or 2011''; and
       (2) in subclause (III), by striking ``January 1, 2010'' and 
     inserting ``January 1, 2012''.

     SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL 
                   RECLASSIFICATIONS.

       (a) In General.--Subsection (a) of section 106 of division 
     B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 
     1395 note), as amended by section 117 of the Medicare, 
     Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
     173) and section 124 of the Medicare Improvements for 
     Patients and Providers Act of 2008 (Public Law 110-275), is 
     amended by striking ``September 30, 2009'' and inserting 
     ``September 30, 2011''.
       (b) Use of Particular Wage Index for Fiscal Year 2010.--For 
     purposes of implementation of the amendment made by 
     subsection (a) for fiscal year 2010, the Secretary shall use 
     the hospital wage index that was promulgated by the Secretary 
     in the Federal Register on August 27, 2009 (74 Fed. Reg. 
     43754), and any subsequent corrections.

     SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.

       Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 
     1395w-4(e)(1)(E)) is amended by striking ``before January 1, 
     2010'' and inserting ``before January 1, 2012''.

     SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF 
                   CERTAIN PHYSICIAN PATHOLOGY SERVICES.

       Section 542(c) of the Medicare, Medicaid, and SCHIP 
     Benefits Improvement and Protection Act of 2000 (as enacted 
     into law by section 1(a)(6) of Public Law 106-554), as 
     amended by section 732 of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4 
     note), section 104 of division B of the Tax Relief and Health 
     Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the 
     Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public 
     Law 110-173), and section 136 of the Medicare Improvements 
     for Patients and Providers Act of 1008 (Public Law 110-275), 
     is amended by striking ``and 2009'' and inserting ``2009, 
     2010, and 2011''.

     SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.

       (a) In General.--Section 1834(l)(13) of the Social Security 
     Act (42 U.S.C. 1395m(l)(13)) is amended--
       (1) in subparagraph (A)--
       (A) in the matter preceding clause (i), by striking 
     ``before January 1, 2010'' and inserting ``before January 1, 
     2012''; and
       (B) in each of clauses (i) and (ii), by striking ``before 
     January 1, 2010'' and inserting ``before January 1, 2012''.
       (b) Air Ambulance Improvements.--Section 146(b)(1) of the 
     Medicare Improvements for Patients and Providers Act of 2008 
     (Public Law 110-275) is amended by striking ``ending on 
     December 31, 2009'' and inserting ``ending on December 31, 
     2011''.

              TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

  Subtitle A--Improving and Simplifying Financial Assistance for Low 
                     Income Medicare Beneficiaries

     SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS 
                   PROGRAM AND LOW-INCOME SUBSIDY PROGRAM.

       (a) Application of Highest Level Permitted Under LIS to All 
     Subsidy Eligible Individuals.--
       (1) In general.--Section 1860D-14(a)(1) of the Social 
     Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the 
     matter before subparagraph (A), by inserting ``(or, beginning 
     with 2012, paragraph (3)(E))'' after ``paragraph (3)(D)''.
       (2) Annual increase in lis resource test.--Section 1860D-
     14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i)) 
     is amended--
       (A) by striking ``and'' at the end of subclause (I);
       (B) in subclause (II), by inserting ``(before 2012)'' after 
     ``subsequent year'';
       (C) by striking the period at the end of subclause (II) and 
     inserting a semicolon;
       (D) by inserting after subclause (II) the following new 
     subclauses:

       ``(III) for 2012, $17,000 (or $34,000 in the case of the 
     combined value of the individual's assets or resources and 
     the assets or resources of the individual's spouse); and
       ``(IV) for a subsequent year, the dollar amounts specified 
     in this subclause (or subclause (III)) for the previous year 
     increased by the annual percentage increase in the consumer 
     price index (all items; U.S. city average) as of September of 
     such previous year.''; and

       (E) in the last sentence, by inserting ``or (IV)'' after 
     ``subclause (II)''.
       (3) Application of lis test under medicare savings 
     program.--Section 1905(p)(1)(C) of such Act (42 U.S.C. 
     1396d(p)(1)(C)) is amended--
       (A) by striking ``effective beginning with January 1, 
     2010'' and inserting ``effective for the period beginning 
     with January 1, 2010, and ending with December 31, 2011''; 
     and
       (B) by inserting before the period at the end the 
     following: ``or, effective beginning with January 1, 2012, 
     whose resources (as so determined) do not exceed the maximum 
     resource level applied for the year under subparagraph (E) of 
     section 1860D-14(a)(3) (determined without regard to the life 
     insurance policy exclusion provided under subparagraph (G) of 
     such section) applicable to an individual or to the 
     individual and the individual's spouse (as the case may 
     be)''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to eligibility determinations for income-related 
     subsidies and medicare cost-sharing furnished for periods 
     beginning on or after January 1, 2012.

     SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN 
                   NON-INSTITUTIONALIZED FULL-BENEFIT DUAL 
                   ELIGIBLE INDIVIDUALS.

       (a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social 
     Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
       (1) by striking ``Institutionalized individuals.--In'' and 
     inserting ``Elimination of cost-sharing for certain full-
     benefit dual eligible individuals.--

       ``(I) Institutionalized individuals.--In''; and

       (2) by adding at the end the following new subclause:

       ``(II) Certain other individuals.--In the case of an 
     individual who is a full-benefit dual eligible individual and 
     with respect to whom there has been a determination that but 
     for the provision of home and community based care (whether 
     under section 1915, 1932, or under a waiver under section 
     1115) the individual would require the level of care provided 
     in a hospital or a nursing facility or intermediate care 
     facility for the mentally retarded the cost of which could be 
     reimbursed under the State plan under title XIX, the 
     elimination of any beneficiary coinsurance described in 
     section 1860D-2(b)(2) (for all amounts through the total 
     amount of expenditures at which benefits are available under 
     section 1860D-2(b)(4)).''.

       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to drugs dispensed on or after January 1, 2011.

     SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.

       (a) Administrative Verification of Income and Resources 
     Under the Low-income Subsidy Program.--
       (1) In general.--Clause (iii) of section 1860D-14(a)(3)(E) 
     of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is 
     amended to read as follows:
       ``(iii) Certification of income and resources.--For 
     purposes of applying this section--

       ``(I) an individual shall be permitted to apply on the 
     basis of self-certification of income and resources; and
       ``(II) matters attested to in the application shall be 
     subject to appropriate methods of verification without the 
     need of the individual to provide additional documentation, 
     except in extraordinary situations as determined by the 
     Commissioner.''.

       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply beginning January 1, 2010.

[[Page 27282]]

       (b) Disclosures to Facilitate Identification of Individuals 
     Likely to Be Ineligible for the Low-income Assistance Under 
     the Medicare Prescription Drug Program to Assist Social 
     Security Administration's Outreach to Eligible Individuals.--
     For provision authorizing disclosure of return information to 
     facilitate identification of individuals likely to be 
     ineligible for low-income subsidies under Medicare 
     prescription drug program, see section 1801.

     SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR 
                   RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.

       (a) In General.--In the case of a retroactive LIS 
     enrollment beneficiary who is enrolled under a prescription 
     drug plan under part D of title XVIII of the Social Security 
     Act (or an MA-PD plan under part C of such title), the 
     beneficiary (or any eligible third party) is entitled to 
     reimbursement by the plan for covered drug costs incurred by 
     the beneficiary during the retroactive coverage period of the 
     beneficiary in accordance with subsection (b) and in the case 
     of such a beneficiary described in subsection (c)(4)(A)(i), 
     such reimbursement shall be made automatically by the plan 
     upon receipt of appropriate notice the beneficiary is 
     eligible for assistance described in such subsection 
     (c)(4)(A)(i) without further information required to be filed 
     with the plan by the beneficiary.
       (b) Administrative Requirements Relating to 
     Reimbursements.--
       (1) Line-item description.--Each reimbursement made by a 
     prescription drug plan or MA-PD plan under subsection (a) 
     shall include a line-item description of the items for which 
     the reimbursement is made.
       (2) Timing of reimbursements.--A prescription drug plan or 
     MA-PD plan must make a reimbursement under subsection (a) to 
     a retroactive LIS enrollment beneficiary, with respect to a 
     claim, not later than 45 days after--
       (A) in the case of a beneficiary described in subsection 
     (c)(4)(A)(i), the date on which the plan receives notice from 
     the Secretary that the beneficiary is eligible for assistance 
     described in such subsection; or
       (B) in the case of a beneficiary described in subsection 
     (c)(4)(A)(ii), the date on which the beneficiary files the 
     claim with the plan.
       (3) Reporting requirement.--For each month beginning with 
     January 2011, each prescription drug plan and each MA-PD plan 
     shall report to the Secretary the following:
       (A) The number of claims the plan has readjudicated during 
     the month due to a beneficiary becoming retroactively 
     eligible for subsidies available under section 1860D-14 of 
     the Social Security Act.
       (B) The total value of the readjudicated claim amount for 
     the month.
       (C) The Medicare Health Insurance Claims Number of 
     beneficiaries for whom claims were readjudicated.
       (D) For the claims described in subparagraphs (A) and (B), 
     an attestation to the Administrator of the Centers for 
     Medicare & Medicaid Services of the total amount of 
     reimbursement the plan has provided to beneficiaries for 
     premiums and cost-sharing that the beneficiary overpaid for 
     which the plan received payment from the Centers for Medicare 
     & Medicaid Services.
       (c) Definitions.--For purposes of this section:
       (1) Covered drug costs.--The term ``covered drug costs'' 
     means, with respect to a retroactive LIS enrollment 
     beneficiary enrolled under a prescription drug plan under 
     part D of title XVIII of the Social Security Act (or an MA-PD 
     plan under part C of such title), the amount by which--
       (A) the costs incurred by such beneficiary during the 
     retroactive coverage period of the beneficiary for covered 
     part D drugs, premiums, and cost-sharing under such title; 
     exceeds
       (B) such costs that would have been incurred by such 
     beneficiary during such period if the beneficiary had been 
     both enrolled in the plan and recognized by such plan as 
     qualified during such period for the low income subsidy under 
     section 1860D-14 of the Social Security Act to which the 
     individual is entitled.
       (2) Eligible third party.--The term ``eligible third 
     party'' means, with respect to a retroactive LIS enrollment 
     beneficiary, an organization or other third party that is 
     owed payment on behalf of such beneficiary for covered drug 
     costs incurred by such beneficiary during the retroactive 
     coverage period of such beneficiary.
       (3) Retroactive coverage period.--The term ``retroactive 
     coverage period'' means--
       (A) with respect to a retroactive LIS enrollment 
     beneficiary described in paragraph (4)(A)(i), the period--
       (i) beginning on the effective date of the assistance 
     described in such paragraph for which the individual is 
     eligible; and
       (ii) ending on the date the plan effectuates the status of 
     such individual as so eligible; and
       (B) with respect to a retroactive LIS enrollment 
     beneficiary described in paragraph (4)(A)(ii), the period--
       (i) beginning on the date the individual is both entitled 
     to benefits under part A, or enrolled under part B, of title 
     XVIII of the Social Security Act and eligible for medical 
     assistance under a State plan under title XIX of such Act; 
     and
       (ii) ending on the date the plan effectuates the status of 
     such individual as a full-benefit dual eligible individual 
     (as defined in section 1935(c)(6) of such Act).
       (4) Retroactive lis enrollment beneficiary.--
       (A) In general.--The term ``retroactive LIS enrollment 
     beneficiary'' means an individual who--
       (i) is enrolled in a prescription drug plan under part D of 
     title XVIII of the Social Security Act (or an MA-PD plan 
     under part C of such title) and subsequently becomes eligible 
     as a full-benefit dual eligible individual (as defined in 
     section 1935(c)(6) of such Act), an individual receiving a 
     low-income subsidy under section 1860D-14 of such Act, an 
     individual receiving assistance under the Medicare Savings 
     Program implemented under clauses (i), (iii), and (iv) of 
     section 1902(a)(10)(E) of such Act, or an individual 
     receiving assistance under the supplemental security income 
     program under section 1611 of such Act; or
       (ii) subject to subparagraph (B)(i), is a full-benefit dual 
     eligible individual (as defined in section 1935(c)(6) of such 
     Act) who is automatically enrolled in such a plan under 
     section 1860D-1(b)(1)(C) of such Act.
       (B) Exception for beneficiaries enrolled in rfp plan.--
       (i) In general.--In no case shall an individual described 
     in subparagraph (A)(ii) include an individual who is 
     enrolled, pursuant to a RFP contract described in clause 
     (ii), in a prescription drug plan offered by the sponsor of 
     such plan awarded such contract.
       (ii) RFP contract described.--The RFP contract described in 
     this section is a contract entered into between the Secretary 
     and a sponsor of a prescription drug plan pursuant to the 
     Centers for Medicare & Medicaid Services' request for 
     proposals issued on February 17, 2009, relating to Medicare 
     part D retroactive coverage for certain low income 
     beneficiaries, or a similar subsequent request for proposals.

     SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.

       (a) In General.--Section 1860D-1(b)(1)(C) of the Social 
     Security Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by 
     adding after ``PDP region'' the following: ``or through use 
     of an intelligent assignment process that is designed to 
     maximize the access of such individual to necessary 
     prescription drugs while minimizing costs to such individual 
     and to the program under this part to the greatest extent 
     possible. In the case the Secretary enrolls such individuals 
     through use of an intelligent assignment process, such 
     process shall take into account the extent to which 
     prescription drugs necessary for the individual are covered 
     in the case of a PDP sponsor of a prescription drug plan that 
     uses a formulary, the use of prior authorization or other 
     restrictions on access to coverage of such prescription drugs 
     by such a sponsor, and the overall quality of a prescription 
     drug plan as measured by quality ratings established by the 
     Secretary''
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect for contract years beginning with 2012.

     SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT 
                   PROCESS FOR CERTAIN SUBSIDY ELIGIBLE 
                   INDIVIDUALS.

       (a) Special Enrollment Period.--Section 1860D-1(b)(3)(D) of 
     the Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is 
     amended to read as follows:
       ``(D) Subsidy eligible individuals.--In the case of an 
     individual (as determined by the Secretary) who is determined 
     under subparagraph (B) of section 1860D-14(a)(3) to be a 
     subsidy eligible individual.''.
       (b) Automatic Enrollment.--Section 1860D-1(b)(1) of the 
     Social Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by 
     adding at the end the following new subparagraph:
       ``(D) Special rule for subsidy eligible individuals.--The 
     process established under subparagraph (A) shall include, in 
     the case of an individual described in section 1860D-
     1(b)(3)(D) who fails to enroll in a prescription drug plan or 
     an MA-PD plan during the special enrollment established under 
     such section applicable to such individual, the application 
     of the assignment process described in subparagraph (C) to 
     such individual in the same manner as such assignment process 
     applies to a part D eligible individual described in such 
     subparagraph (C). Nothing in the previous sentence shall 
     prevent an individual described in such sentence from 
     declining enrollment in a plan determined appropriate by the 
     Secretary (or in the program under this part) or from 
     changing such enrollment.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to subsidy determinations made for months 
     beginning with January 2011.

     SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE AND 
                   QUALITY BONUS PAYMENTS IN CALCULATION OF LOW 
                   INCOME SUBSIDY BENCHMARK.

       (a) In General.--Section 1860D-14(b)(2)(B)(iii) of the 
     Social Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is 
     amended by inserting before the period the following: 
     ``before the application of the monthly rebate computed under 
     section 1854(b)(1)(C)(i) for that plan and year involved and, 
     in the

[[Page 27283]]

     case of a qualifying plan in a qualifying county, before the 
     application of the increase under section 1853(o) for that 
     plan and year involved''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to subsidy determinations made for months 
     beginning with January 2011.

                Subtitle B--Reducing Health Disparities

     SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.

       (a) Ensuring Effective Communication by the Centers for 
     Medicare & Medicaid Services.--
       (1) Study on medicare payments for language services.--The 
     Secretary of Health and Human Services shall conduct a study 
     that examines the extent to which Medicare service providers 
     utilize, offer, or make available language services for 
     beneficiaries who are limited English proficient and ways 
     that Medicare should develop payment systems for language 
     services.
       (2) Analyses.--The study shall include an analysis of each 
     of the following:
       (A) How to develop and structure appropriate payment 
     systems for language services for all Medicare service 
     providers.
       (B) The feasibility of adopting a payment methodology for 
     on-site interpreters, including interpreters who work as 
     independent contractors and interpreters who work for 
     agencies that provide on-site interpretation, pursuant to 
     which such interpreters could directly bill Medicare for 
     services provided in support of physician office services for 
     an LEP Medicare patient.
       (C) The feasibility of Medicare contracting directly with 
     agencies that provide off-site interpretation including 
     telephonic and video interpretation pursuant to which such 
     contractors could directly bill Medicare for the services 
     provided in support of physician office services for an LEP 
     Medicare patient.
       (D) The feasibility of modifying the existing Medicare 
     resource-based relative value scale (RBRVS) by using 
     adjustments (such as multipliers or add-ons) when a patient 
     is LEP.
       (E) How each of options described in a previous paragraph 
     would be funded and how such funding would affect physician 
     payments, a physician's practice, and beneficiary cost-
     sharing.
       (F) The extent to which providers under parts A and B of 
     title XVIII of the Social Security Act, MA organizations 
     offering Medicare Advantage plans under part C of such title 
     and PDP sponsors of a prescription drug plan under part D of 
     such title utilize, offer, or make available language 
     services for beneficiaries with limited English proficiency.
       (G) The nature and type of language services provided by 
     States under title XIX of the Social Security Act and the 
     extent to which such services could be utilized by 
     beneficiaries and providers under title XVIII of such Act.
       (H) The extent to which interpreters and translators 
     providing services to Medicare beneficiaries under title 
     XVIII of such Act are trained or accredited.
       (3) Variation in payment system described.--The payment 
     systems described in paragraph (2)(A) may allow variations 
     based upon types of service providers, available delivery 
     methods, and costs for providing language services including 
     such factors as--
       (A) the type of language services provided (such as 
     provision of health care or health care related services 
     directly in a non-English language by a bilingual provider or 
     use of an interpreter);
       (B) type of interpretation services provided (such as in-
     person, telephonic, video interpretation);
       (C) the methods and costs of providing language services 
     (including the costs of providing language services with 
     internal staff or through contract with external independent 
     contractors or agencies, or both);
       (D) providing services for languages not frequently 
     encountered in the United States; and
       (E) providing services in rural areas.
       (4) Report.--The Secretary shall submit a report on the 
     study conducted under subsection (a) to appropriate 
     committees of Congress not later than 12 months after the 
     date of the enactment of this Act.
       (5) Exemption from paperwork reduction act.--Chapter 35 of 
     title 44, United States Code (commonly known as the 
     ``Paperwork Reduction Act'' ), shall not apply for purposes 
     of carrying out this subsection.
       (6) Authorization of appropriations.--The Secretary shall 
     provide for the transfer, from the Federal Supplementary 
     Medical Insurance Trust Fund under section 1841 of the Social 
     Security Act (42 U.S.C. 1395t) of $2,000,000 for purposes of 
     carrying out this subsection.
       (b) Health Plans.--Section 1857(g)(1) of the Social 
     Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
       (1) by striking ``or'' at the end of subparagraph (F);
       (2) by adding ``or'' at the end of subparagraph (G); and
       (3) by inserting after subparagraph (G) the following new 
     subparagraph:
       ``(H) fails substantially to provide language services to 
     limited English proficient beneficiaries enrolled in the plan 
     that are required under law;''.

     SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE 
                   BENEFICIARIES WITH LIMITED ENGLISH PROFICIENCY 
                   BY PROVIDING REIMBURSEMENT FOR CULTURALLY AND 
                   LINGUISTICALLY APPROPRIATE SERVICES.

       (a) In General.--Not later than 6 months after the date of 
     the completion of the study described in section 1221(a) of 
     this Act, the Secretary, acting through the Centers for 
     Medicare & Medicaid Services and the Center for Medicare and 
     Medicaid Innovation established under section 1115A of the 
     Social Security Act (as added by section 1907) and consistent 
     with the applicable provisions of such section, shall carry 
     out a demonstration program under which the Secretary shall 
     award not fewer than 24 3-year grants to eligible Medicare 
     service providers (as described in subsection (b)(1)) to 
     improve effective communication between such providers and 
     Medicare beneficiaries who are living in communities where 
     racial and ethnic minorities, including populations that face 
     language barriers, are underserved with respect to such 
     services. In designing and carrying out the demonstration the 
     Secretary shall take into consideration the results of the 
     study conducted under section 1221(a) of this Act and adjust, 
     as appropriate, the distribution of grants so as to better 
     target Medicare beneficiaries who are in the greatest need of 
     language services. The Secretary shall not authorize a grant 
     larger than $500,000 over three years for any grantee.
       (b) Eligibility; Priority.--
       (1) Eligibility.--To be eligible to receive a grant under 
     subsection (a) an entity shall--
       (A) be--
       (i) a provider of services under part A of title XVIII of 
     the Social Security Act;
       (ii) a service provider under part B of such title;
       (iii) a part C organization offering a Medicare part C plan 
     under part C of such title; or
       (iv) a PDP sponsor of a prescription drug plan under part D 
     of such title; and
       (B) prepare and submit to the Secretary an application, at 
     such time, in such manner, and accompanied by such additional 
     information as the Secretary may require.
       (2) Priority.--
       (A) Distribution.--To the extent feasible, in awarding 
     grants under this section, the Secretary shall award--
       (i) at least 6 grants to providers of services described in 
     paragraph (1)(A)(i);
       (ii) at least 6 grants to service providers described in 
     paragraph (1)(A)(ii);
       (iii) at least 6 grants to organizations described in 
     paragraph (1)(A)(iii); and
       (iv) at least 6 grants to sponsors described in paragraph 
     (1)(A)(iv).
       (B) For community organizations.--The Secretary shall give 
     priority to applicants that have developed partnerships with 
     community organizations or with agencies with experience in 
     language access.
       (C) Variation in grantees.--The Secretary shall also ensure 
     that the grantees under this section represent, among other 
     factors--
       (i) different types of language services provided and of 
     service providers and organizations under parts A through D 
     of title XVIII of the Social Security Act;
       (ii) variations in languages needed and their frequency of 
     use;
       (iii) urban and rural settings;
       (iv) at least two geographic regions, as defined by the 
     Secretary; and
       (v) at least two large metropolitan statistical areas with 
     diverse populations.
       (c) Use of Funds.--
       (1) In general.--A grantee shall use grant funds received 
     under this section to pay for the provision of competent 
     language services to Medicare beneficiaries who are limited 
     English proficient. Competent interpreter services may be 
     provided through on-site interpretation, telephonic 
     interpretation, or video interpretation or direct provision 
     of health care or health care related services by a bilingual 
     health care provider. A grantee may use bilingual providers, 
     staff, or contract interpreters. A grantee may use grant 
     funds to pay for competent translation services. A grantee 
     may use up to 10 percent of the grant funds to pay for 
     administrative costs associated with the provision of 
     competent language services and for reporting required under 
     subsection (e).
       (2) Organizations.--Grantees that are part C organizations 
     or PDP sponsors must ensure that their network providers 
     receive at least 50 percent of the grant funds to pay for the 
     provision of competent language services to Medicare 
     beneficiaries who are limited English proficient, including 
     physicians and pharmacies.
       (3) Determination of payments for language services.--
     Payments to grantees shall be calculated based on the 
     estimated numbers of limited English proficient Medicare 
     beneficiaries in a grantee's service area utilizing--
       (A) data on the numbers of limited English proficient 
     individuals who speak English less than ``very well'' from 
     the most recently available data from the Bureau of the 
     Census or other State-based study the Secretary determines 
     likely to yield accurate data regarding the number of such 
     individuals served by the grantee; or
       (B) the grantee's own data if the grantee routinely 
     collects data on Medicare beneficiaries' primary language in 
     a manner determined by the Secretary to yield accurate

[[Page 27284]]

     data and such data shows greater numbers of limited English 
     proficient individuals than the data listed in subparagraph 
     (A).
       (4) Limitations.--
       (A) Reporting.--Payments shall only be provided under this 
     section to grantees that report their costs of providing 
     language services as required under subsection (e) and may be 
     modified annually at the discretion of the Secretary. If a 
     grantee fails to provide the reports under such section for 
     the first year of a grant, the Secretary may terminate the 
     grant and solicit applications from new grantees to 
     participate in the subsequent two years of the demonstration 
     program.
       (B) Type of services.--
       (i) In general.--Subject to clause (ii), payments shall be 
     provided under this section only to grantees that utilize 
     competent bilingual staff or competent interpreter or 
     translation services which--

       (I) if the grantee operates in a State that has statewide 
     health care interpreter standards, meet the State standards 
     currently in effect; or
       (II) if the grantee operates in a State that does not have 
     statewide health care interpreter standards, utilizes 
     competent interpreters who follow the National Council on 
     Interpreting in Health Care's Code of Ethics and Standards of 
     Practice.

       (ii) Exemptions.--The requirements of clause (i) shall not 
     apply--

       (I) in the case of a Medicare beneficiary who is limited 
     English proficient (who has been informed in the 
     beneficiary's primary language of the availability of free 
     interpreter and translation services) and who requests the 
     use of family, friends, or other persons untrained in 
     interpretation or translation and the grantee documents the 
     request in the beneficiary's record; and
       (II) in the case of a medical emergency where the delay 
     directly associated with obtaining a competent interpreter or 
     translation services would jeopardize the health of the 
     patient.

     Nothing in clause (ii)(II) shall be construed to exempt 
     emergency rooms or similar entities that regularly provide 
     health care services in medical emergencies from having in 
     place systems to provide competent interpreter and 
     translation services without undue delay.
       (d) Assurances.--Grantees under this section shall--
       (1) ensure that appropriate clinical and support staff 
     receive ongoing education and training in linguistically 
     appropriate service delivery;
       (2) ensure the linguistic competence of bilingual 
     providers;
       (3) offer and provide appropriate language services at no 
     additional charge to each patient with limited English 
     proficiency at all points of contact, in a timely manner 
     during all hours of operation;
       (4) notify Medicare beneficiaries of their right to receive 
     language services in their primary language;
       (5) post signage in the languages of the commonly 
     encountered group or groups present in the service area of 
     the organization; and
       (6) ensure that--
       (A) primary language data are collected for recipients of 
     language services and are consistent with standards developed 
     under section 1709(b)(3)(B)(iv) of the Public Health Service 
     Act, as added by section 2402 of this Act, to the extent such 
     standards are available upon the initiation of the 
     demonstration; and
       (B) consistent with the privacy protections provided under 
     the regulations promulgated pursuant to section 264(c) of the 
     Health Insurance Portability and Accountability Act of 1996 
     (42 U.S.C. 1320d-2 note), if the recipient of language 
     services is a minor or is incapacitated, the primary language 
     of the parent or legal guardian is collected and utilized.
       (e) Reporting Requirements.--Grantees under this section 
     shall provide the Secretary with reports at the conclusion of 
     the each year of a grant under this section. Each report 
     shall include at least the following information:
       (1) The number of Medicare beneficiaries to whom language 
     services are provided.
       (2) The languages of those Medicare beneficiaries.
       (3) The types of language services provided (such as 
     provision of services directly in non-English language by a 
     bilingual health care provider or use of an interpreter).
       (4) Type of interpretation (such as in-person, telephonic, 
     or video interpretation).
       (5) The methods of providing language services (such as 
     staff or contract with external independent contractors or 
     agencies).
       (6) The length of time for each interpretation encounter.
       (7) The costs of providing language services (which may be 
     actual or estimated, as determined by the Secretary).
       (8) An account of the training or accreditation of 
     bilingual staff, interpreters, or translators providing 
     services under this demonstration.
       (f) No Cost Sharing.--Limited English proficient Medicare 
     beneficiaries shall not have to pay cost-sharing or co-pays 
     for language services provided through this demonstration 
     program.
       (g) Evaluation and Report.--The Secretary shall conduct an 
     evaluation of the demonstration program under this section 
     and shall submit to the appropriate committees of Congress a 
     report not later than 1 year after the completion of the 
     program. The report shall include the following:
       (1) An analysis of the patient outcomes and costs of 
     furnishing care to the limited English proficient Medicare 
     beneficiaries participating in the project as compared to 
     such outcomes and costs for limited English proficient 
     Medicare beneficiaries not participating.
       (2) The effect of delivering culturally and linguistically 
     appropriate services on beneficiary access to care, 
     utilization of services, efficiency and cost-effectiveness of 
     health care delivery, patient satisfaction, and select health 
     outcomes.
       (3) The extent to which bilingual staff, interpreters, and 
     translators providing services under such demonstration were 
     trained or accredited and the nature of accreditation or 
     training needed by type of provider, service, or other 
     category as determined by the Secretary to ensure the 
     provision of high-quality interpretation, translation, or 
     other language services to Medicare beneficiaries if such 
     services are expanded pursuant to subsection (c) of section 
     1907 of this Act.
       (4) Recommendations, if any, regarding the extension of 
     such project to the entire Medicare program.
       (h) Accreditation or Training for Providers of 
     Interpretation, Translation or Language Services in 
     Medicare.--
       (1) In general.--
       (A) Designation of standards.--If the Secretary, pursuant 
     to section 1907(c) of this Act, expands the model initially 
     developed through the demonstration program under this 
     section, the Secretary shall use the results of the study 
     under section 1221 and the demonstration under this section 
     to designate standards for training or accreditation. The 
     Secretary may designate one or more training or accreditation 
     organizations, as appropriate for the nature and type of 
     interpretation and translation services provided to Medicare 
     beneficiaries to ensure that payments are made only for 
     approved services by trained or accredited language services 
     providers.
       (B) Alternatives to training or accreditation.--If the 
     Secretary designates one or more training or accreditation 
     organizations but determines that accreditation is not 
     available in all languages for which payments may be 
     initiated, the Secretary shall provide payments for and 
     accept alternatives to training or accreditation for certain 
     languages, including languages of lesser diffusion. The 
     Secretary must ensure that the alternatives to training or 
     accreditation provide, at a minimum--
       (i) a determination that the interpreter is proficient and 
     able to communicate information accurately in both English 
     and in the language for which interpreting is needed;
       (ii) an attestation from the interpreter to comply with and 
     adhere to the role of an interpreter as defined by the 
     National Code of Ethics and National Standards of Practice as 
     published by the National Council on Interpreting in Health 
     Care; and
       (iii) an attestation to adhere to HIPAA privacy and 
     security law, as defined in section 3009(a)(2) of the Public 
     Health Service Act, to the same extent as the healthcare 
     provider for whom interpreting is provided.
       (C) Modifiers, add-ons, and other forms of payment.--If the 
     Secretary decides that modifiers, add-ons, or other forms of 
     payment may be made for the provision of services directly by 
     bilingual providers, the Secretary shall designate standards 
     to ensure the competency of such providers delivering such 
     services in a non-English language.
       (2) Consultation with stakeholders and considerations for 
     accreditation or training.--
       (A) Consultation.--In designating accreditation or training 
     requirements under this subsection, the Secretary shall 
     consult with patients, providers, organizations that advocate 
     on behalf of limited English proficient individuals, and 
     other individuals or entities determined appropriate by the 
     Secretary.
       (B) Considerations.--In designating accreditation or 
     training requirements under this section, the Secretary shall 
     consider, as appropriate--
       (i) standards for qualifications of health care 
     interpreters who interpret infrequently encountered 
     languages;
       (ii) standards for qualifications of health care 
     interpreters who interpret in languages of lesser diffusion;
       (iii) standards for training of interpreters; and
       (iv) standards for continuing education of interpreters.
       (i) General Provisions.--Nothing in this section shall be 
     construed to limit otherwise existing obligations of 
     recipients of Federal financial assistance under title VI of 
     the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or 
     any other statute.
       (j) Appropriations.--There are appropriated to carry out 
     this section, in equal parts from the Federal Hospital 
     Insurance Trust Fund and the Federal Supplementary Medical 
     Insurance Trust Fund, $16,000,000 for each fiscal year of the 
     demonstration program.

[[Page 27285]]



     SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.

       (a) In General.--The Secretary of Health and Human Services 
     shall enter into an arrangement with the Institute of 
     Medicine under which the Institute will prepare and publish, 
     not later than 3 years after the date of the enactment of 
     this Act, a report on the impact of language access services 
     on the health and health care of limited English proficient 
     populations.
       (b) Contents.--Such report shall include--
       (1) recommendations on the development and implementation 
     of policies and practices by health care organizations and 
     providers for limited English proficient patient populations;
       (2) a description of the effect of providing language 
     access services on quality of health care and access to care 
     and reduced medical error; and
       (3) a description of the costs associated with or savings 
     related to provision of language access services.

     SEC. 1224. DEFINITIONS.

       In this subtitle:
       (1) Bilingual.--The term ``bilingual'' with respect to an 
     individual means a person who has sufficient degree of 
     proficiency in two languages and can ensure effective 
     communication can occur in both languages.
       (2) Competent interpreter services.--The term ``competent 
     interpreter services'' means a trans-language rendition of a 
     spoken message in which the interpreter comprehends the 
     source language and can speak comprehensively in the target 
     language to convey the meaning intended in the source 
     language. The interpreter knows health and health-related 
     terminology and provides accurate interpretations by choosing 
     equivalent expressions that convey the best matching and 
     meaning to the source language and captures, to the greatest 
     possible extent, all nuances intended in the source message.
       (3) Competent translation services.--The term ``competent 
     translation services'' means a trans-language rendition of a 
     written document in which the translator comprehends the 
     source language and can write comprehensively in the target 
     language to convey the meaning intended in the source 
     language. The translator knows health and health-related 
     terminology and provides accurate translations by choosing 
     equivalent expressions that convey the best matching and 
     meaning to the source language and captures, to the greatest 
     possible extent, all nuances intended in the source document.
       (4) Effective communication.--The term ``effective 
     communication'' means an exchange of information between the 
     provider of health care or health care-related services and 
     the limited English proficient recipient of such services 
     that enables limited English proficient individuals to 
     access, understand, and benefit from health care or health 
     care-related services.
       (5) Interpreting/interpretation.--The terms 
     ``interpreting'' and ``interpretation'' mean the transmission 
     of a spoken message from one language into another, 
     faithfully, accurately, and objectively.
       (6) Health care services.--The term ``health care 
     services'' means services that address physical as well as 
     mental health conditions in all care settings.
       (7) Health care-related services.--The term ``health care-
     related services'' means human or social services programs or 
     activities that provide access, referrals or links to health 
     care.
       (8) Language access.--The term ``language access'' means 
     the provision of language services to an LEP individual 
     designed to enhance that individual's access to, 
     understanding of or benefit from health care or health care-
     related services.
       (9) Language services.--The term ``language services'' 
     means provision of health care services directly in a non-
     English language, interpretation, translation, and non-
     English signage.
       (10) Limited english proficient.--The term ``limited 
     English proficient'' or ``LEP'' with respect to an individual 
     means an individual who speaks a primary language other than 
     English and who cannot speak, read, write or understand the 
     English language at a level that permits the individual to 
     effectively communicate with clinical or nonclinical staff at 
     an entity providing health care or health care related 
     services.
       (11) Medicare beneficiary.--The term ``Medicare 
     beneficiary'' means an individual entitled to benefits under 
     part A of title XVIII of the Social Security Act or enrolled 
     under part B of such title.
       (12) Medicare program.--The term ``Medicare program'' means 
     the programs under parts A through D of title XVIII of the 
     Social Security Act.
       (13) Service provider.--The term ``service provider'' 
     includes all suppliers, providers of services, or entities 
     under contract to provide coverage, items or services under 
     any part of title XVIII of the Social Security Act.

                 Subtitle C--Miscellaneous Improvements

     SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.

       Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
     1395l(g)(5)), as amended by section 141 of the Medicare 
     Improvements for Patients and Providers Act of 2008 (Public 
     Law 110-275), is amended by striking ``December 31, 2009'' 
     and inserting ``December 31, 2011''.

     SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE 
                   DRUGS FOR KIDNEY TRANSPLANT PATIENTS AND OTHER 
                   RENAL DIALYSIS PROVISIONS.

       (a) Provision of Appropriate Coverage of Immunosuppressive 
     Drugs Under the Medicare Program for Kidney Transplant 
     Recipients.--
       (1) Continued entitlement to immunosuppressive drugs.--
       (A) Kidney transplant recipients.--Section 226A(b)(2) of 
     the Social Security Act (42 U.S.C. 426-1(b)(2)) is amended by 
     inserting ``(except for coverage of immunosuppressive drugs 
     under section 1861(s)(2)(J))'' before ``, with the thirty-
     sixth month''.
       (B) Application.--Section 1836 of such Act (42 U.S.C. 
     1395o) is amended--
       (i) by striking ``Every individual who'' and inserting 
     ``(a) In General.--Every individual who''; and
       (ii) by adding at the end the following new subsection:
       ``(b) Special Rules Applicable to Individuals Only Eligible 
     for Coverage of Immunosuppressive Drugs.--
       ``(1) In general.--In the case of an individual whose 
     eligibility for benefits under this title has ended on or 
     after January 1, 2012, except for the coverage of 
     immunosuppressive drugs by reason of section 226A(b)(2), the 
     following rules shall apply:
       ``(A) The individual shall be deemed to be enrolled under 
     this part for purposes of receiving coverage of such drugs.
       ``(B) The individual shall be responsible for providing for 
     payment of the portion of the premium under section 1839 
     which is not covered under the Medicare savings program (as 
     defined in section 1144(c)(7)) in order to receive such 
     coverage.
       ``(C) The provision of such drugs shall be subject to the 
     application of--
       ``(i) the deductible under section 1833(b); and
       ``(ii) the coinsurance amount applicable for such drugs (as 
     determined under this part).
       ``(D) If the individual is an inpatient of a hospital or 
     other entity, the individual is entitled to receive coverage 
     of such drugs under this part.
       ``(2) Establishment of procedures in order to implement 
     coverage.--The Secretary shall establish procedures for--
       ``(A) identifying individuals that are entitled to coverage 
     of immunosuppressive drugs by reason of section 226A(b)(2); 
     and
       ``(B) distinguishing such individuals from individuals that 
     are enrolled under this part for the complete package of 
     benefits under this part.''.
       (C) Technical amendment to correct duplicate subsection 
     designation.--Subsection (c) of section 226A of such Act (42 
     U.S.C. 426-1), as added by section 201(a)(3)(D)(ii) of the 
     Social Security Independence and Program Improvements Act of 
     1994 (Public Law 103-296; 108 Stat. 1497), is redesignated as 
     subsection (d).
       (2) Extension of secondary payer requirements for esrd 
     beneficiaries.--Section 1862(b)(1)(C) of such Act (42 U.S.C. 
     1395y(b)(1)(C)) is amended by adding at the end the following 
     new sentence: ``With regard to immunosuppressive drugs 
     furnished on or after the date of the enactment of the 
     Affordable Health Care for America Act, this subparagraph 
     shall be applied without regard to any time limitation.''.
       (b) Medicare Coverage for ESRD Patients.--Section 1881 of 
     such Act is further amended--
       (1) in subsection (b)(14)(B)(iii), by inserting ``, 
     including oral drugs that are not the oral equivalent of an 
     intravenous drug (such as oral phosphate binders and 
     calcimimetics),'' after ``other drugs and biologicals'';
       (2) in subsection (b)(14)(E)(ii)--
       (A) in the first sentence--
       (i) by striking ``a one-time election to be excluded from 
     the phase-in'' and inserting ``an election, with respect to 
     2011, 2012, or 2013, to be excluded from the phase-in (or the 
     remainder of the phase-in)''; and
       (ii) by adding before the period at the end the following: 
     ``for such year and for each subsequent year during the 
     phase-in described in clause (i)''; and
       (B) in the second sentence--
       (i) by striking ``January 1, 2011'' and inserting ``the 
     first date of such year''; and
       (ii) by inserting ``and at a time'' after ``form and 
     manner''; and
       (3) in subsection (h)(4)(E), by striking ``lesser'' and 
     inserting ``greater''.

     SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CONSULTATION.

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

[[Page 27286]]



             ``Voluntary Advance Care Planning Consultation

       ``(hhh)(1) Subject to paragraphs (3) and (4), the term 
     `voluntary advance care planning consultation' means an 
     optional consultation between the individual and a 
     practitioner described in paragraph (2) regarding advance 
     care planning. Such consultation may include the following, 
     as specified by the Secretary:
       ``(A) An explanation by the practitioner of advance care 
     planning, including a review of key questions and 
     considerations, advance directives (including living wills 
     and durable powers of attorney) and their uses.
       ``(B) An explanation by the practitioner of the role and 
     responsibilities of a health care proxy and of the continuum 
     of end-of-life services and supports available, including 
     palliative care and hospice, and benefits for such services 
     and supports that are available under this title.
       ``(C) An explanation by the practitioner of physician 
     orders regarding life sustaining treatment or similar orders, 
     in States where such orders or similar orders exist.
       ``(2) A practitioner described in this paragraph is--
       ``(A) a physician (as defined in subsection (r)(1)); and
       ``(B) another health care professional (as specified by the 
     Secretary and who has the authority under State law to sign 
     orders for life sustaining treatments, such as a nurse 
     practitioner or physician assistant).
       ``(3) An individual may receive the voluntary advance care 
     planning care planning consultation provided for under this 
     subsection no more than once every 5 years unless there is a 
     significant change in the health or health-related condition 
     of the individual.
       ``(4) For purposes of this section, the term `order 
     regarding life sustaining treatment' means, with respect to 
     an individual, an actionable medical order relating to the 
     treatment of that individual that effectively communicates 
     the individual's preferences regarding life sustaining 
     treatment, is signed and dated by a practitioner, and is in a 
     form that permits it to be followed by health care 
     professionals across the continuum of care.''.
       (b) Construction.--The voluntary advance care planning 
     consultation described in section 1861(hhh) of the Social 
     Security Act, as added by subsection (a), shall be completely 
     optional. Nothing in this section shall--
       (1) require an individual to complete an advance directive, 
     an order for life sustaining treatment, or other advance care 
     planning document;
       (2) require an individual to consent to restrictions on the 
     amount, duration, or scope of medical benefits an individual 
     is entitled to receive under this title; or
       (3) encourage the promotion of suicide or assisted suicide.
       (c) Payment.--Section 1848(j)(3) of such Act (42 U.S.C. 
     1395w-4(j)(3)) is amended by inserting ``(2)(FF),'' after 
     ``(2)(EE),''.
       (d) Frequency Limitation.--Section 1862(a) of such Act (42 
     U.S.C. 1395y(a)) is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (N), by striking ``and'' at the end;
       (B) in subparagraph (O) by striking the semicolon at the 
     end and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(P) in the case of voluntary advance care planning 
     consultations (as defined in paragraph (1) of section 
     1861(hhh)), which are performed more frequently than is 
     covered under such section;''; and
       (2) in paragraph (7), by striking ``or (K)'' and inserting 
     ``(K), or (P)''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to consultations furnished on or after January 1, 
     2011.

     SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF 
                   LIMITED ENROLLMENT PENALTY FOR TRICARE 
                   BENEFICIARIES.

       (a) Part B Special Enrollment Period.--
       (1) In general.--Section 1837 of the Social Security Act 
     (42 U.S.C. 1395p) is amended by adding at the end the 
     following new subsection:
       ``(l)(1) In the case of any individual who is a covered 
     beneficiary (as defined in section 1072(5) of title 10, 
     United States Code) at the time the individual is entitled to 
     hospital insurance benefits under part A under section 226(b) 
     or section 226A and who is eligible to enroll but who has 
     elected not to enroll (or to be deemed enrolled) during the 
     individual's initial enrollment period, there shall be a 
     special enrollment period described in paragraph (2).
       ``(2) The special enrollment period described in this 
     paragraph, with respect to an individual, is the 12-month 
     period beginning on the day after the last day of the initial 
     enrollment period of the individual or, if later, the 12-
     month period beginning with the month the individual is 
     notified of enrollment under this section.
       ``(3) In the case of an individual who enrolls during the 
     special enrollment period provided under paragraph (1), the 
     coverage period under this part shall begin on the first day 
     of the month in which the individual enrolls or, at the 
     option of the individual, on the first day of the second 
     month following the last month of the individual's initial 
     enrollment period.
       ``(4) The Secretary of Defense shall establish a method for 
     identifying individuals described in paragraph (1) and 
     providing notice to them of their eligibility for enrollment 
     during the special enrollment period described in paragraph 
     (2).''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to elections made on or after the date of the 
     enactment of this Act.
       (b) Waiver of Increase of Premium.--
       (1) In general.--Section 1839(b) of the Social Security Act 
     (42 U.S.C. 1395r(b)) is amended by striking ``section 
     1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of 
     section 1837''.
       (2) Effective date.--
       (A) In general.--The amendment made by paragraph (1) shall 
     apply with respect to elections made on or after the date of 
     the enactment of this Act.
       (B) Rebates for certain disabled and esrd beneficiaries.--
       (i) In general.--With respect to premiums for months on or 
     after January 2005 and before the month of the enactment of 
     this Act, no increase in the premium shall be effected for a 
     month in the case of any individual who is a covered 
     beneficiary (as defined in section 1072(5) of title 10, 
     United States Code) at the time the individual is entitled to 
     hospital insurance benefits under part A of title XVIII of 
     the Social Security Act under section 226(b) or 226A of such 
     Act, and who is eligible to enroll, but who has elected not 
     to enroll (or to be deemed enrolled), during the individual's 
     initial enrollment period, and who enrolls under this part 
     within the 12-month period that begins on the first day of 
     the month after the month of notification of entitlement 
     under this part.
       (ii) Consultation with department of defense.--The 
     Secretary of Health and Human Services shall consult with the 
     Secretary of Defense in identifying individuals described in 
     this paragraph.
       (iii) Rebates.--The Secretary of Health and Human Services 
     shall establish a method for providing rebates of premium 
     increases paid for months on or after January 1, 2005, and 
     before the month of the enactment of this Act for which a 
     penalty was applied and collected.

     SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX YEAR IN CASE 
                   OF GAINS FROM SALE OF PRIMARY RESIDENCE IN 
                   COMPUTING PART B INCOME-RELATED PREMIUM.

       (a) In General.--Section 1839(i)(4)(C)(ii)(II) of the 
     Social Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is 
     amended by inserting ``sale of primary residence,'' after 
     ``divorce of such individual,''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to premiums and payments for years beginning with 
     2011.

     SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS 
                   AIDS.

       (a) In General.--The Secretary of Health and Human 
     Services, acting through the Center for Medicare and Medicaid 
     Innovation established under section 1115A of the Social 
     Security Act (as added by section 1907) and consistent with 
     the applicable provisions of such section, shall establish a 
     shared decision making demonstration program (in this 
     subsection referred to as the ``program'') under the Medicare 
     program using patient decision aids to meet the objective of 
     improving the understanding by Medicare beneficiaries of 
     their medical treatment options, as compared to comparable 
     Medicare beneficiaries who do not participate in a shared 
     decision making process using patient decision aids.
       (b) Sites.--
       (1) Enrollment.--The Secretary shall enroll in the program 
     not more than 30 eligible providers who have experience in 
     implementing, and have invested in the necessary 
     infrastructure to implement, shared decision making using 
     patient decision aids.
       (2) Application.--An eligible provider seeking to 
     participate in the program shall submit to the Secretary an 
     application at such time and containing such information as 
     the Secretary may require.
       (3) Preference.--In enrolling eligible providers in the 
     program, the Secretary shall give preference to eligible 
     providers that--
       (A) have documented experience in using patient decision 
     aids for the conditions identified by the Secretary and in 
     using shared decision making;
       (B) have the necessary information technology 
     infrastructure to collect the information required by the 
     Secretary for reporting purposes; and
       (C) are trained in how to use patient decision aids and 
     shared decision making.
       (c) Follow-up Counseling Visit.--
       (1) In general.--An eligible provider participating in the 
     program shall routinely schedule Medicare beneficiaries for a 
     counseling visit after the viewing of such a patient decision 
     aid to answer any questions the beneficiary may have with 
     respect to the medical care of the condition involved and to 
     assist the beneficiary in thinking through how their 
     preferences and concerns relate to their medical care.
       (2) Payment for follow-up counseling visit.--The Secretary 
     shall establish procedures for making payments for such 
     counseling visits provided to Medicare beneficiaries under 
     the program. Such procedures shall provide for the 
     establishment--

[[Page 27287]]

       (A) of a code (or codes) to represent such services; and
       (B) of a single payment amount for such service that 
     includes the professional time of the health care provider 
     and a portion of the reasonable costs of the infrastructure 
     of the eligible provider such as would be made under the 
     applicable payment systems to that provider for similar 
     covered services.
       (d) Costs of Aids.--An eligible provider participating in 
     the program shall be responsible for the costs of selecting, 
     purchasing, and incorporating such patient decision aids into 
     the provider's practice, and reporting data on quality and 
     outcome measures under the program.
       (e) Funding.--The Secretary shall provide for the transfer 
     from the Federal Supplementary Medical Insurance Trust Fund 
     established under section 1841 of the Social Security Act (42 
     U.S.C. 1395t) of such funds as are necessary for the costs of 
     carrying out the program.
       (f) Waiver Authority.--The Secretary may waive such 
     requirements of titles XI and XVIII of the Social Security 
     Act (42 U.S.C. 1301 et seq. and 1395 et seq.) as may be 
     necessary for the purpose of carrying out the program.
       (g) Report.--Not later than 12 months after the date of 
     completion of the program, the Secretary shall submit to 
     Congress a report on such program, together with 
     recommendations for such legislation and administrative 
     action as the Secretary determines to be appropriate. The 
     final report shall include an evaluation of the impact of the 
     use of the program on health quality, utilization of health 
     care services, and on improving the quality of life of such 
     beneficiaries.
       (h) Definitions.--In this section:
       (1) Eligible provider.--The term ``eligible provider'' 
     means the following:
       (A) A primary care practice.
       (B) A specialty practice.
       (C) A multispecialty group practice.
       (D) A hospital.
       (E) A rural health clinic.
       (F) A Federally qualified health center (as defined in 
     section 1861(aa)(4) of the Social Security Act (42 U.S.C. 
     1395x(aa)(4)).
       (G) An integrated delivery system.
       (H) A State cooperative entity that includes the State 
     government and at least one other health care provider which 
     is set up for the purpose of testing shared decision making 
     and patient decision aids.
       (2) Patient decision aid.--The term ``patient decision 
     aid'' means an educational tool (such as the Internet, a 
     video, or a pamphlet) that helps patients (or, if 
     appropriate, the family caregiver of the patient) understand 
     and communicate their beliefs and preferences related to 
     their treatment options, and to decide with their health care 
     provider what treatments are best for them based on their 
     treatment options, scientific evidence, circumstances, 
     beliefs, and preferences.
       (3) Shared decision making.--The term ``shared decision 
     making'' means a collaborative process between patient and 
     clinician that engages the patient in decision making, 
     provides patients with information about trade-offs among 
     treatment options, and facilitates the incorporation of 
     patient preferences and values into the medical plan.

    TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND 
                            COORDINATED CARE

     SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

       Title XVIII of the Social Security Act is amended by 
     inserting after section 1866D, as added by section 1152(f), 
     the following new section:


             ``accountable care organization pilot program

       ``Sec. 1866E.  (a) Establishment.--
       ``(1) In General.--The Secretary shall conduct a pilot 
     program (in this section referred to as the `pilot program') 
     to test different payment incentive models, including (to the 
     extent practicable) the specific payment incentive models 
     described in subsection (c), designed to reduce the growth of 
     expenditures and improve health outcomes in the provision of 
     items and services under this title to applicable 
     beneficiaries (as defined in subsection (e)) by qualifying 
     accountable care organizations (as defined in subsection 
     (b)(1)) in order to--
       ``(A) promote accountability for a patient population and 
     coordinate items and services under parts A and B (and may 
     include Part D, if the Secretary determines appropriate);
       ``(B) encourage investment in infrastructure and redesigned 
     care processes for high quality and efficient service 
     delivery; and
       ``(C) reward physician practices and other physician 
     organizational models for the provision of high quality and 
     efficient health care services.
       ``(2) Scope.--The Secretary shall set specific goals for 
     the number of accountable care organizations, participating 
     practitioners, and patients served in the initial tests under 
     the pilot program to ensure that the pilot program is of 
     sufficient size and scope to--
       ``(A) test the approach involved in a variety of settings, 
     including urban, rural, and underserved areas; and
       ``(B) subject to subsection (g)(1), disseminate such 
     approach rapidly on a national basis.
     To the extent that the Secretary finds a qualifying 
     accountable care organization model to be successful in 
     improving quality and reducing costs, the Secretary shall 
     seek to implement such models on as large a geographic scale 
     as practical and economical.
       ``(b) Qualifying Accountable Care Organizations (ACOs).--
       ``(1) Qualifying aco defined.--In this section:
       ``(A) In general.--The terms `qualifying accountable care 
     organization' and `qualifying ACO' mean a group of physicians 
     or other physician organizational model (as defined in 
     subparagraph (D)) that--
       ``(i) is organized at least in part for the purpose of 
     providing physicians' services; and
       ``(ii) meets such criteria as the Secretary determines to 
     be appropriate to participate in the pilot program, including 
     the criteria specified in paragraph (2).
       ``(B) Inclusion of other providers of services and 
     suppliers.--Nothing in this subsection shall be construed as 
     preventing a qualifying ACO from including a hospital or any 
     other provider of services or supplier furnishing items or 
     services for which payment may be made under this title that 
     is affiliated with the ACO under an arrangement structured so 
     that such provider or supplier participates in the pilot 
     program and shares in any incentive payments under the pilot 
     program.
       ``(C) Physician.--The term `physician' includes, except as 
     the Secretary may otherwise provide, any individual who 
     furnishes services for which payment may be made as 
     physicians' services under this title.
       ``(D) Other physician organizational model.--The term 
     `other physician organization model' means, with respect to a 
     qualifying ACO any model of organization under which 
     physicians enter into agreements with other providers of 
     services for the purposes of participation in the pilot 
     program in order to provide high quality and efficient health 
     care services and share in any incentive payments under such 
     program
       ``(E) Other services.--Nothing in this paragraph shall be 
     construed as preventing a qualifying ACO from furnishing 
     items or services, for which payment may not be made under 
     this title, for purposes of achieving performance goals under 
     the pilot program.
       ``(2) Qualifying criteria.--The following are criteria 
     described in this paragraph for an organized group of 
     physicians to be a qualifying ACO:
       ``(A) The group has a legal structure that would allow the 
     group to receive and distribute incentive payments under this 
     section.
       ``(B) The group includes a sufficient number of primary 
     care physicians (regardless of specialty) for the applicable 
     beneficiaries for whose care the group is accountable (as 
     determined by the Secretary).
       ``(C) The group reports on quality measures in such form, 
     manner, and frequency as specified by the Secretary (which 
     may be for the group, for providers of services and 
     suppliers, or both).
       ``(D) The group reports to the Secretary (in a form, manner 
     and frequency as specified by the Secretary) such data as the 
     Secretary determines appropriate to monitor and evaluate the 
     pilot program.
       ``(E) The group provides notice to applicable beneficiaries 
     regarding the pilot program (as determined appropriate by the 
     Secretary).
       ``(F) The group contributes to a best practices network or 
     website, that shall be maintained by the Secretary for the 
     purpose of sharing strategies on quality improvement, care 
     coordination, and efficiency that the groups believe are 
     effective.
       ``(G) The group utilizes patient-centered processes of 
     care, including those that emphasize patient and caregiver 
     involvement in planning and monitoring of ongoing care 
     management plan.
       ``(H) The group meets other criteria determined to be 
     appropriate by the Secretary.
       ``(c) Specific Payment Incentive Models.--The specific 
     payment incentive models described in this subsection are the 
     following:
       ``(1) Performance target model.--Under the performance 
     target model under this paragraph (in this paragraph referred 
     to as the `performance target model'):
       ``(A) In general.--A qualifying ACO qualifies to receive an 
     incentive payment if expenditures for items and services for 
     applicable beneficiaries are less than a target spending 
     level or a target rate of growth. The incentive payment shall 
     be made only if savings are greater than would result from 
     normal variation in expenditures for items and services 
     covered under parts A and B (and may include Part D, if the 
     Secretary determines appropriate).
       ``(B) Computation of performance target.--
       ``(i) In general.--The Secretary shall establish a 
     performance target for each qualifying ACO comprised of a 
     base amount (described in clause (ii)) increased to the 
     current year by an adjustment factor (described in clause 
     (iii)). Such a target may be established on a per capita 
     basis or adjusted for risk, as the Secretary determines to be 
     appropriate.

[[Page 27288]]

       ``(ii) Base amount.--For purposes of clause (i), the base 
     amount in this subparagraph is equal to the average total 
     payments (or allowed charges) under parts A and B (and may 
     include part D, if the Secretary determines appropriate) for 
     applicable beneficiaries for whom the qualifying ACO 
     furnishes items and services in a base period determined by 
     the Secretary. Such base amount may be determined on a per 
     capita basis or adjusted for risk.
       ``(iii) Adjustment factor.--For purposes of clause (i), the 
     adjustment factor in this clause may equal an annual per 
     capita amount that reflects changes in expenditures from the 
     period of the base amount to the current year that would 
     represent an appropriate performance target for applicable 
     beneficiaries (as determined by the Secretary).
       ``(iv) Rebasing.--Under this model the Secretary shall 
     periodically rebase the base expenditure amount described in 
     clause (ii).
       ``(C) Meeting target.--
       ``(i) In general.--Subject to clause (ii), a qualifying ACO 
     that meets or exceeds annual quality and performance targets 
     for a year shall receive an incentive payment for such year 
     equal to a portion (as determined appropriate by the 
     Secretary) of the amount by which payments under this title 
     for such year are estimated to be below the performance 
     target for such year, as determined by the Secretary. The 
     Secretary may establish a cap on incentive payments for a 
     year for a qualifying ACO.
       ``(ii) Limitation.--The Secretary shall limit incentive 
     payments to each qualifying ACO under this paragraph as 
     necessary to ensure that the aggregate expenditures with 
     respect to applicable beneficiaries for such ACOs under this 
     title (inclusive of incentive payments described in this 
     subparagraph) do not exceed the amount that the Secretary 
     estimates would be expended for such ACO for such 
     beneficiaries if the pilot program under this section were 
     not implemented.
       ``(D) Reporting and other requirements.--In carrying out 
     such model, the Secretary may (as the Secretary determines to 
     be appropriate) incorporate reporting requirements, incentive 
     payments, and penalties related to the physician quality 
     reporting initiative (PQRI), electronic prescribing, 
     electronic health records, and other similar initiatives 
     under section 1848, and may use alternative criteria than 
     would otherwise apply under such section for determining 
     whether to make such payments. The incentive payments 
     described in this subparagraph shall not be included in the 
     limit described in subparagraph (C)(ii) or in the performance 
     target model described in this paragraph.
       ``(2) Partial capitation model.--
       ``(A) In general.--Subject to subparagraph (B), a partial 
     capitation model described in this paragraph (in this 
     paragraph referred to as a `partial capitation model') is a 
     model in which a qualifying ACO would be at financial risk 
     for some, but not all, of the items and services covered 
     under parts A and B (and may include part D, if the Secretary 
     determines appropriate), such as at risk for some or all 
     physicians' services or all items and services under part B. 
     The Secretary may limit a partial capitation model to ACOs 
     that are highly integrated systems of care and to ACOs 
     capable of bearing risk, as determined to be appropriate by 
     the Secretary.
       ``(B) No additional program expenditures.--Payments to a 
     qualifying ACO for items and services under this title for 
     applicable beneficiaries for a year under the partial 
     capitation model shall be established in a manner that does 
     not result in spending more for such ACO for such 
     beneficiaries than would otherwise be expended for such ACO 
     for such beneficiaries for such year if the pilot program 
     were not implemented, as estimated by the Secretary.
       ``(3) Other payment models.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary may develop other payment models that meet the 
     goals of this pilot program to improve quality and 
     efficiency.
       ``(B) No additional program expenditures.--Subparagraph (B) 
     of paragraph (2) shall apply to a payment model under 
     subparagraph (A) in a similar manner as such subparagraph (B) 
     applies to the payment model under paragraph (2).
       ``(d) Annual Quality Targets.--
       ``(1) In general.--The Secretary shall establish annual 
     quality targets that qualifying ACOs must meet to receive 
     incentive payments, operate at financial risk, or otherwise 
     participate in alternative financing models under this 
     section. The Secretary shall establish a process for 
     developing annual targets based on ACO reporting of multiple 
     quality measures. In selecting measures the Secretary shall--
       ``(A) for years one and two of each ACOs participation in 
     the pilot program established by this section, require 
     reporting of a starter set of measures focused on clinical 
     care, care coordination and patient experience of care; and
       ``(B) for each subsequent year, require reporting of a more 
     comprehensive set of clinical outcomes measures, care 
     coordination measures and patient experience of care 
     measures.
       ``(2) Measure selection.--To the extent feasible, the 
     Secretary shall select measures that reflect national 
     priorities for quality improvement and patient-centered care 
     consistent with the measures developed under section 
     1192(c)(1).
       ``(e) Applicable Beneficiaries.--
       ``(1) In general.--In this section, the term `applicable 
     beneficiary' means, with respect to a qualifying ACO, an 
     individual who--
       ``(A) is enrolled under part B and entitled to benefits 
     under part A;
       ``(B) is not enrolled in a Medicare Advantage plan under 
     part C or a PACE program under section 1894; and
       ``(C) meets such other criteria as the Secretary determines 
     appropriate, which may include criteria relating to frequency 
     of contact with physicians in the ACO
       ``(2) Following applicable beneficiaries.--The Secretary 
     may monitor data on expenditures and quality of services 
     under this title after an applicable beneficiary discontinues 
     receiving services under this title through a qualifying ACO.
       ``(f) Implementation.--
       ``(1) Starting date.--The pilot program shall begin no 
     later than January 1, 2012. An agreement with a qualifying 
     ACO under the pilot program may cover a multi-year period of 
     between 3 and 5 years.
       ``(2) Waiver.--The Secretary may waive such provisions of 
     this title (including section 1877) and title XI in the 
     manner the Secretary determines necessary in order implement 
     the pilot program.
       ``(3) Performance results reports.--The Secretary shall 
     report performance results to qualifying ACOs under the pilot 
     program at least annually.
       ``(4) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(A) the elements, parameters, scope, and duration of the 
     pilot program;
       ``(B) the selection of qualifying ACOs for the pilot 
     program;
       ``(C) the establishment of targets, measurement of 
     performance, determinations with respect to whether savings 
     have been achieved and the amount of savings;
       ``(D) determinations regarding whether, to whom, and in 
     what amounts incentive payments are paid; and
       ``(E) decisions about the extension of the program under 
     subsection (h), expansion of the program under subsection (i) 
     or extensions under subsections (j) or (k).
       ``(5) Administration.--Chapter 35 of title 44, United 
     States Code shall not apply to this section.
       ``(g) Evaluation; Monitoring.--
       ``(1) In general.--The Secretary shall evaluate the payment 
     incentive model for each qualifying ACO under the pilot 
     program to assess impacts on beneficiaries, providers of 
     services, suppliers and the program under this title. The 
     Secretary shall make such evaluation publicly available 
     within 60 days of the date of completion of such report.
       ``(2) Monitoring.--The Inspector General of the Department 
     of Health and Human Services shall provide for monitoring of 
     the operation of ACOs under the pilot program with regard to 
     violations of section 1877 (popularly known as the `Stark 
     law').
       ``(h) Extension of Pilot Agreement With Successful 
     Organizations.--
       ``(1) Reports to congress.--Not later than 2 years after 
     the date the first agreement is entered into under this 
     section, and biennially thereafter for six years, the 
     Secretary shall submit to Congress and make publicly 
     available a report on the use of ACO payment models under the 
     pilot program. Each report shall address the impact of the 
     use of those models on expenditures, access, and quality 
     under this title.
       ``(2) Extension.--Subject to the report provided under 
     paragraph (1), with respect to a qualifying ACO, the 
     Secretary may extend the duration of the agreement for such 
     ACO under the pilot program as the Secretary determines 
     appropriate if--
       ``(A) the ACO receives incentive payments with respect to 
     any of the first 4 years of the pilot agreement and is 
     consistently meeting quality standards or
       ``(B) the ACO is consistently exceeding quality standards 
     and is not increasing spending under the program.
       ``(3) Termination.--The Secretary may terminate an 
     agreement with a qualifying ACO under the pilot program if 
     such ACO did not receive incentive payments or consistently 
     failed to meet quality standards in any of the first 3 years 
     under the program.
       ``(i) Expansion to Additional ACOs.--
       ``(1) Testing and refinement of payment incentive models.--
     Subject to the evaluation described in subsection (g), the 
     Secretary may enter into agreements under the pilot program 
     with additional qualifying ACOs to further test and refine 
     payment incentive models with respect to qualifying ACOs.
       ``(2) Expanding use of successful models to program 
     implementation.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary may issue regulations to implement, on a permanent 
     basis, 1 or more models if, and to the extent that, such 
     models are beneficial to the program under this title, as 
     determined by the Secretary.

[[Page 27289]]

       ``(B) Certification.--The Chief Actuary of the Centers for 
     Medicare & Medicaid Services shall certify that 1 or more of 
     such models described in subparagraph (A) would result in 
     estimated spending that would be less than what spending 
     would otherwise be estimated to be in the absence of such 
     expansion.
       ``(j) Treatment of Physician Group Practice 
     Demonstration.--
       ``(1) Extension.--The Secretary may enter in to an 
     agreement with a qualifying ACO under the demonstration under 
     section 1866A, subject to rebasing and other modifications 
     deemed appropriate by the Secretary, until the pilot program 
     under this section is operational.
       ``(2) Transition.--For purposes of extension of an 
     agreement with a qualifying ACO under subsection (h)(2), the 
     Secretary shall treat receipt of an incentive payment for a 
     year by an organization under the physician group practice 
     demonstration pursuant to section 1866A as a year for which 
     an incentive payment is made under such subsection, as long 
     as such practice group practice organization meets the 
     criteria under subsection (b)(2).
       ``(k) Additional Provisions.--
       ``(1) Authority for separate incentive arrangements.--The 
     Secretary may create separate incentive arrangements 
     (including using multiple years of data, varying thresholds, 
     varying shared savings amounts, and varying shared savings 
     limits) for different categories of qualifying ACOs to 
     reflect variation in average annual attributable expenditures 
     and other matters the Secretary deems appropriate.
       ``(2) Encouragement of participation of smaller 
     organizations.--In order to encourage the participation of 
     smaller accountable care organizations under the pilot 
     program, the Secretary may limit a qualifying ACO's exposure 
     to high cost patients under the program.
       ``(3) Involvement in private payer and other third party 
     arrangements.--The Secretary may give preference to ACOs who 
     are participating in similar arrangements with other payers.
       ``(4) Antidiscrimination limitation.--The Secretary shall 
     not enter into an agreement with an entity to provide health 
     care items or services under the pilot program, or with an 
     entity to administer the program, unless such entity 
     guarantees that it will not deny, limit, or condition the 
     coverage or provision of benefits under the program, for 
     individuals eligible to be enrolled under such program, based 
     on any health status-related factor described in section 
     2702(a)(1) of the Public Health Service Act.
       ``(5) Funding.--For purposes of administering and carrying 
     out the pilot program, other than for payments for items and 
     services furnished under this title and incentive payments 
     under subsection (c)(1), in addition to funds otherwise 
     appropriated, there are appropriated to the Secretary for the 
     Center for Medicare & Medicaid Services Program Management 
     Account $25,000,000 for each of fiscal years 2010 through 
     2014 and $20,000,000 for fiscal year 2015. Amounts 
     appropriated under this paragraph for a fiscal year shall be 
     available until expended.
       ``(6) No duplication in payments to physicians in multiple 
     pilots.--The Secretary shall not make payments under this 
     section to any physician group that is paid under section 
     1866F (relating to medical homes) or section 1866G (relating 
     to independence at home).''.

     SEC. 1302. MEDICAL HOME PILOT PROGRAM.

       (a) In General.--Title XVIII of the Social Security Act is 
     amended by inserting after section 1866E, as inserted by 
     section 1301, the following new section:


                      ``medical home pilot program

       ``Sec. 1866F.  (a) Establishment and Medical Home Models.--
       ``(1) Establishment of pilot program.--The Secretary shall 
     establish a medical home pilot program (in this section 
     referred to as the `pilot program') for the purpose of 
     evaluating the feasibility and advisability of reimbursing 
     qualified patient-centered medical homes for furnishing 
     medical home services (as defined under subsection (b)(1)) to 
     beneficiaries (as defined in subsection (b)(4)) and to 
     targeted high need beneficiaries (as defined in subsection 
     (c)(1)(C)).
       ``(2) Scope.--Subject to subsection (g), the Secretary 
     shall set specific goals for the number of practices and 
     communities, and the number of patients served, under the 
     pilot program in the initial tests to ensure that the pilot 
     program is of sufficient size and scope to--
       ``(A) test the approach involved in a variety of settings, 
     including urban, rural, and underserved areas; and
       ``(B) subject to subsection (e)(1), disseminate such 
     approach rapidly on a national basis.
     To the extent that the Secretary finds a medical home model 
     to be successful in improving quality and reducing costs, the 
     Secretary shall implement such model on as large a geographic 
     scale as practical and economical.
       ``(3) Models of medical homes in the pilot program.--The 
     pilot program shall evaluate each of the following medical 
     home models:
       ``(A) Independent patient-centered medical home model.--
     Independent patient-centered medical home model under 
     subsection (c).
       ``(B) Community-based medical home model.--Community-based 
     medical home model under subsection (d).
       ``(4) Participation of nurse practitioners and physician 
     assistants.--
       ``(A) Nothing in this section shall be construed as 
     preventing a nurse practitioner from leading a patient 
     centered medical home so long as--
       ``(i) all the requirements of this section are met; and
       ``(ii) the nurse practitioner is acting in a manner that is 
     consistent with State law.
       ``(B) Nothing in this section shall be construed as 
     preventing a physician assistant from participating in a 
     patient centered medical home so long as--
       ``(i) all the requirements of this section are met; and
       ``(ii) the physician assistant is acting in a manner that 
     is consistent with State law.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Patient-centered medical home services.--The term 
     `patient-centered medical home services' means services 
     that--
       ``(A) provide beneficiaries with direct and ongoing access 
     to a primary care or principal care physician or nurse 
     practitioner who accepts responsibility for providing first 
     contact, continuous and comprehensive care to such 
     beneficiary;
       ``(B) coordinate the care provided to a beneficiary by a 
     team of individuals at the practice level across office, 
     provider of services, and home settings led by a primary care 
     or principal care physician or nurse practitioner, as needed 
     and appropriate;
       ``(C) provide for all the patient's health care needs or 
     take responsibility for appropriately arranging care with 
     other qualified physicians or providers for all stages of 
     life;
       ``(D) provide continuous access to care and communication 
     with participating beneficiaries;
       ``(E) provide support for patient self-management, 
     proactive and regular patient monitoring, support for family 
     caregivers, use patient-centered processes, and coordination 
     with community resources;
       ``(F) integrate readily accessible, clinically useful 
     information on participating patients that enables the 
     practice to treat such patients comprehensively and 
     systematically; and
       ``(G) implement evidence-based guidelines and apply such 
     guidelines to the identified needs of beneficiaries over time 
     and with the intensity needed by such beneficiaries.
       ``(2) Primary care.--The term `primary care' means health 
     care that is provided by a physician, nurse practitioner, or 
     physician assistant who practices in the field of family 
     medicine, general internal medicine, geriatric medicine, or 
     pediatric medicine.
       ``(3) Principal care.--The term `principal care' means 
     integrated, accessible health care that is provided by a 
     physician who is a medical specialist or subspecialist that 
     addresses the majority of the personal health care needs of 
     patients with chronic conditions requiring the specialist's 
     or subspecialist's expertise, and for whom the specialist or 
     subspecialist assumes care management.
       ``(4) Beneficiaries.--The term `beneficiaries' means, with 
     respect to a qualifying medical home, an individual who--
       ``(A) is enrolled under part B and entitled to benefits 
     under part A;
       ``(B) is not enrolled in a Medicare Advantage plan under 
     part C or a PACE program under section 1894; and
       ``(C) meets such other criteria as the Secretary determines 
     appropriate.
       ``(c) Independent Patient-centered Medical Home Model.--
       ``(1) In general.--
       ``(A) Payment authority.--Under the independent patient-
     centered medical home model under this subsection, the 
     Secretary shall make payments for medical home services 
     furnished by an independent patient-centered medical home (as 
     defined in subparagraph (B)) pursuant to paragraph (3) for 
     targeted high need beneficiaries (as defined in subparagraph 
     (C)).
       ``(B) Independent patient-centered medical home defined.--
     In this section, the term `independent patient-centered 
     medical home' means a physician-directed or nurse-
     practitioner-directed practice that is qualified under 
     paragraph (2) as--
       ``(i) providing beneficiaries with patient-centered medical 
     home services; and
       ``(ii) meets such other requirements as the Secretary may 
     specify.
       ``(C) Targeted high need beneficiary defined.--For purposes 
     of this subsection, the term `targeted high need beneficiary' 
     means a beneficiary who, based on a risk score as specified 
     by the Secretary, is generally within the upper 50th 
     percentile of Medicare beneficiaries.
       ``(D) Beneficiary election to participate.--The Secretary 
     shall determine an appropriate method of ensuring that 
     beneficiaries have agreed to participate in the pilot 
     program.
       ``(E) Implementation.--The pilot program under this 
     subsection shall begin no later than 12 months after the date 
     of the enactment of this section and shall operate for 5 
     years.

[[Page 27290]]

       ``(2) Qualification process for patient-centered medical 
     homes.--The Secretary shall establish a process for practices 
     to qualify as medical homes.
       ``(3)  Payment.--
       ``(A) Establishment of methodology.--The Secretary shall 
     establish a methodology for the payment for medical home 
     services furnished by independent patient-centered medical 
     homes. Under such methodology, the Secretary shall adjust 
     payments to medical homes based on beneficiary risk scores to 
     ensure that higher payments are made for higher risk 
     beneficiaries.
       ``(B) Per beneficiary per month payments.--Under such 
     payment methodology, the Secretary shall pay independent 
     patient-centered medical homes a monthly fee for each 
     targeted high need beneficiary who consents to receive 
     medical home services through such medical home.
       ``(C) Prospective payment.--The fee under subparagraph (B) 
     shall be paid on a prospective basis.
       ``(D) Amount of payment.--In determining the amount of such 
     fee, the Secretary shall consider the following:
       ``(i) The clinical work and practice expenses involved in 
     providing the medical home services provided by the 
     independent patient-centered medical home (such as providing 
     increased access, care coordination, population disease 
     management, and teaching self-care skills for managing 
     chronic illnesses) for which payment is not made under this 
     title as of the date of the enactment of this section.
       ``(ii) Allow for differential payments based on 
     capabilities of the independent patient-centered medical 
     home.
       ``(iii) Use appropriate risk-adjustment in determining the 
     amount of the per beneficiary per month payment under this 
     paragraph in a manner that ensures that higher payments are 
     made for higher risk beneficiaries.
       ``(4) Encouraging participation of variety of practices.--
     The pilot program under this subsection shall be designed to 
     include the participation of physicians in practices with 
     fewer than 10 full-time equivalent physicians, as well as 
     physicians in larger practices, particularly in underserved 
     and rural areas, as well as federally qualified health 
     centers, and rural health centers.
       ``(d) Community-based Medical Home Model.--
       ``(1) In general.--
       ``(A) Authority for payments.--Under the community-based 
     medical home model under this subsection (in this section 
     referred to as the `CBMH model'), the Secretary shall make 
     payments for the furnishing of medical home services by a 
     community-based medical home (as defined in subparagraph (B)) 
     pursuant to paragraph (5)(B) for beneficiaries.
       ``(B) Community-based medical home defined.--In this 
     section, the term `community-based medical home' means a 
     nonprofit community-based or State-based organization or a 
     State that is certified under paragraph (2) as meeting the 
     following requirements:
       ``(i) The organization provides beneficiaries with medical 
     home services.
       ``(ii) The organization provides medical home services 
     under the supervision of and in close collaboration with the 
     primary care or principal care physician, nurse practitioner, 
     or physician assistant designated by the beneficiary as his 
     or her community-based medical home provider.
       ``(iii) The organization employs community health workers, 
     including nurses or other non-physician practitioners, lay 
     health workers, or other persons as determined appropriate by 
     the Secretary, that assist the primary or principal care 
     physician, nurse practitioner, or physician assistant in 
     chronic care management activities such as teaching self-care 
     skills for managing chronic illnesses, transitional care 
     services, care plan setting, nutritional counseling, 
     medication therapy management services for patients with 
     multiple chronic diseases, or help beneficiaries access the 
     health care and community-based resources in their local 
     geographic area.
       ``(iv) The organization meets such other requirements as 
     the Secretary may specify.
       ``(2) Qualification process for community-based medical 
     homes.--The Secretary shall establish a process to provide 
     for the review and qualification of community-based medical 
     homes pursuant to criteria established by the Secretary.
       ``(3) Duration.--The pilot program for community-based 
     medical homes under this subsection shall start no later than 
     2 years after the date of the enactment of this section. Each 
     demonstration site under the pilot program shall operate for 
     a period of up to 5 years after the initial implementation 
     phase, without regard to the receipt of a initial 
     implementation funding under paragraph (6).
       ``(4) Preference.--In selecting sites for the CBMH model, 
     the Secretary shall give preference to applications which 
     seek to eliminate health disparities, as defined in section 
     3171 of the Public Health Service Act and may give preference 
     to any of the following:
       ``(A) Applications that propose to coordinate health care 
     items and services under this title for chronically ill 
     beneficiaries who rely, for primary care, on small physician 
     or nurse practitioner practices, federally qualified health 
     centers, rural health clinics, or other settings with limited 
     resources and scope of services.
       ``(B) Applications that include other third-party payors 
     that furnish medical home services for chronically ill 
     patients covered by such third-party payors.
       ``(C) Applications from States that propose to use the 
     medical home model to coordinate health care services for--
       ``(i) individuals enrolled under this title;
       ``(ii) individuals enrolled under title XIX; and
       ``(iii) full-benefit dual eligible individuals (as defined 
     in section 1935(c)(6)),
     with chronic diseases across a variety of health care 
     settings.
       ``(5)  Payments.--
       ``(A) Establishment of methodology.--The Secretary shall 
     establish a methodology for the payment for medical home 
     services furnished under the CBMH model.
       ``(B) Per beneficiary per month payments.--Under such 
     payment methodology, the Secretary shall make two separate 
     monthly payments for each beneficiary who consents to receive 
     medical home services through such medical home, as follows:
       ``(i) Payment to community-based organization.--One monthly 
     payment to a community-based or State-based organization or 
     State.
       ``(ii) Payment to primary or principal care practice.--One 
     monthly payment to the primary or principal care practice for 
     such beneficiary.
       ``(C) Prospective payment.--The payments under subparagraph 
     (B) shall be paid on a prospective basis.
       ``(D) Amount of payment.--In determining the amount of such 
     payment under subparagraph (B), the Secretary shall consider 
     the following:
       ``(i) The clinical work and practice expenses involved in 
     providing the medical home services provided by the primary 
     or principal care practice (such as providing increased 
     access, care coordination, care planning, population disease 
     management, and teaching self-care skills for managing 
     chronic illnesses) for which payment is not made under this 
     title as of the date of the enactment of this section.
       ``(ii) Use appropriate risk-adjustment in determining the 
     amount of the per beneficiary per month payment under this 
     paragraph.
       ``(iii) In the case of the models described in 
     subparagraphs (B) and (C) of paragraph (4), the Secretary may 
     determine an appropriate payment amount.
       ``(6) Initial implementation funding.--The Secretary may 
     make available initial implementation funding to a non-profit 
     community based or State-based organization or a State that 
     is participating in the pilot program under this subsection. 
     Such organization shall provide the Secretary with a detailed 
     implementation plan that includes how such funds will be 
     used. The Secretary shall select a territory of the United 
     States as one of the locations in which to implement the 
     pilot program under this subsection, unless no organization 
     in a territory is able to comply with the requirements under 
     paragraph (1)(B).
       ``(e) Expansion of Program.--
       ``(1) Evaluation of cost and quality.--The Secretary shall 
     evaluate the pilot program to determine--
       ``(A) the extent to which medical homes result in--
       ``(i) improvement in the quality and coordination of items 
     and services under this title, particularly with regard to 
     the care of complex patients;
       ``(ii) improvement in reducing health disparities;
       ``(iii) reductions in preventable hospitalizations;
       ``(iv) prevention of readmissions;
       ``(v) reductions in emergency room visits;
       ``(vi) improvement in health outcomes, including patient 
     functional status where applicable;
       ``(vii) improvement in patient satisfaction;
       ``(viii) improved efficiency of care such as reducing 
     duplicative diagnostic tests and laboratory tests; and
       ``(ix) reductions in health care expenditures; and
       ``(B) the feasability and advisability of reimbursing 
     medical homes for medical home services under this title on a 
     permanent basis.
       ``(2) Report.--Not later than 60 days after the date of 
     completion of the evaluation under paragraph (1), the 
     Secretary shall submit to Congress and make available to the 
     public a report on the findings of the evaluation under 
     paragraph (1) and the extent to which standards for the 
     certification of medical homes need to be periodically 
     updated.
       ``(3) Expansion of program.--
       ``(A) In general.--Subject to the results of the evaluation 
     under paragraph (1) and subparagraph (B), the Secretary may 
     issue regulations to implement, on a permanent basis, one or 
     more models, if, and to the extent that such model or models, 
     are beneficial to the program under this title, including 
     that such implementation will improve quality of care, as 
     determined by the Secretary.
       ``(B) Certification requirement.--The Secretary may not 
     issue such regulations

[[Page 27291]]

     unless the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that the expansion of the 
     components of the pilot program described in subparagraph (A) 
     would result in estimated spending under this title that 
     would be no more than the level of spending that the 
     Secretary estimates would otherwise be spent under this title 
     in the absence of such expansion.
       ``(C) Updated standards.--The Secretary shall periodically 
     review and update the standards for qualification as an 
     independent patient centered medical home and as a community 
     based medical home and shall establish a process for ensuring 
     that medical homes meet such updated standards, as applicable
       ``(f) Administrative Provisions.--
       ``(1) No duplication in payments for individuals in medical 
     homes.--During any month, the Secretary may not make payments 
     under this section under more than one model or through more 
     than one medical home under any model for the furnishing of 
     medical home services to an individual.
       ``(2) No effect on payment for medical visits.--Payments 
     made under this section are in addition to, and have no 
     effect on the amount of, payment for medical visits made 
     under this title
       ``(3) Administration.--Chapter 35 of title 44, United 
     States Code shall not apply to this section.
       ``(4) No duplication in physician pilot participation.--The 
     Secretary shall not make payments to an independent or 
     community based medical home both under this section and 
     section 1866E or 1866G, unless the pilot program under this 
     section has been implemented on a permanent basis under 
     subsection (e)(3).
       ``(5) Waiver.--The Secretary may waive such provisions of 
     this title and title XI in the manner the Secretary 
     determines necessary in order to implement this section.
       ``(g) Funding.--
       ``(1) Operational costs.--For purposes of administering and 
     carrying out the pilot program (including the design, 
     implementation, technical assistance for and evaluation of 
     such program), in addition to funds otherwise available, 
     there shall be transferred from the Federal Supplementary 
     Medical Insurance Trust Fund under section 1841 to the 
     Secretary for the Centers for Medicare & Medicaid Services 
     Program Management Account $6,000,000 for each of fiscal 
     years 2010 through 2014. Amounts appropriated under this 
     paragraph for a fiscal year shall be available until 
     expended.
       ``(2) Patient-centered medical home services.--In addition 
     to funds otherwise available, there shall be available to the 
     Secretary for the Centers for Medicare & Medicaid Services, 
     from the Federal Supplementary Medical Insurance Trust Fund 
     under section 1841--
       ``(A) $200,000,000 for each of fiscal years 2010 through 
     2014 for payments for medical home services under subsection 
     (c)(3); and
       ``(B) $125,000,000 for each of fiscal years 2012 through 
     2016, for payments under subsection (d)(5).
     Amounts available under this paragraph for a fiscal year 
     shall be available until expended.
       ``(3) Initial implementation.--In addition to funds 
     otherwise available, there shall be available to the 
     Secretary for the Centers for Medicare & Medicaid Services, 
     from the Federal Supplementary Medical Insurance Trust Fund 
     under section 1841, $2,500,000 for each of fiscal years 2010 
     through 2012, under subsection (d)(6). Amounts available 
     under this paragraph for a fiscal year shall be available 
     until expended.
       ``(h) Treatment of TRHCA Medicare Medical Home 
     Demonstration Funding.--
       ``(1) In addition to funds otherwise available for payment 
     of medical home services under subsection (c)(3), there shall 
     also be available the amount provided in subsection (g) of 
     section 204 of division B of the Tax Relief and Health Care 
     Act of 2006 (42 U.S.C. 1395b-1 note), as added by section 133 
     of the Medicare Improvements for Patients and Providers Act 
     of 2008 (Public Law 110-275).
       ``(2) Notwithstanding section 1302(c) of the Affordable 
     Health Care for America Act, in addition to funds provided in 
     paragraph (1) and subsection (g)(2)(A), the funding for 
     medical home services that would otherwise have been 
     available if such section 204 medical home demonstration had 
     been implemented (without regard to subsection (g) of such 
     section) shall be available to the independent patient-
     centered medical home model described in subsection (c).''.
       (b) Effective Date.--The amendment made by this section 
     shall apply to services furnished on or after the date of the 
     enactment of this Act.
       (c) Conforming Repeal.--Section 204 of division B of the 
     Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1 
     note), as amended by section 133(a)(2) of the Medicare 
     Improvements for Patients and Providers Act of 2008 (Public 
     Law 110-275), is repealed.

     SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE 
                   SERVICES.

       (a) In General.--Section 1833 of the Social Security Act is 
     amended by inserting after subsection (o) the following new 
     subsection:
       ``(p) Primary Care Payment Incentives.--
       ``(1) In general.--In the case of primary care services (as 
     defined in paragraph (2)) furnished on or after January 1, 
     2011, by a primary care practitioner (as defined in paragraph 
     (3)) for which amounts are payable under section 1848, in 
     addition to the amount otherwise paid under this part there 
     shall also be paid to the practitioner (or to an employer or 
     facility in the cases described in clause (A) of section 
     1842(b)(6)) (on a monthly or quarterly basis) from the 
     Federal Supplementary Medical Insurance Trust Fund an amount 
     equal 5 percent (or 10 percent if the practitioner 
     predominately furnishes such services in an area that is 
     designated (under section 332(a)(1)(A) of the Public Health 
     Service Act) as a primary care health professional shortage 
     area.
       ``(2) Primary care services defined.--In this subsection, 
     the term `primary care services'--
       ``(A) mean evaluation and management services, without 
     regard to the specialty of the physician furnishing the 
     services, that are procedure codes (for services covered 
     under this title) for--
       ``(i) services in the category designated Evaluation and 
     Management in the Health Care Common Procedure Coding System 
     (established by the Secretary under section 1848(c)(5) as of 
     December 31, 2009, and as subsequently modified by the 
     Secretary); and
       ``(ii) preventive services (as defined in section 1861(iii) 
     for which payment is made under this section; and
       ``(B) includes services furnished by another health care 
     professional that would be described in subparagraph (A) if 
     furnished by a physician.
       ``(3) Primary care practitioner defined.--In this 
     subsection, the term `primary care practitioner'--
       ``(A) means a physician or other health care practitioner 
     (including a nurse practitioner) who--
       ``(i) specializes in family medicine, general internal 
     medicine, general pediatrics, geriatrics, or obstetrics and 
     gynecology; and
       ``(ii) has allowed charges for primary care services that 
     account for at least 50 percent of the physician's or 
     practitioner's total allowed charges under section 1848, as 
     determined by the Secretary for the most recent period for 
     which data are available; and
       ``(B) includes a physician assistant who is under the 
     supervision of a physician described in subparagraph (A).
       ``(4) Limitation on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise, respecting--
       ``(A) any determination or designation under this 
     subsection;
       ``(B) the identification of services as primary care 
     services under this subsection; and
       ``(C) the identification of a practitioner as a primary 
     care practitioner under this subsection.
       ``(5) Coordination with other payments.--
       ``(A) With other primary care incentives.--The provisions 
     of this subsection shall not be taken into account in 
     applying subsections (m) and (u) and any payment under such 
     subsections shall not be taken into account in computing 
     payments under this subsection.
       ``(B) With quality incentives.--Payments under this 
     subsection shall not be taken into account in determining the 
     amounts that would otherwise be paid under this part for 
     purposes of section 1834(g)(2)(B).''.
       (b) Conforming Amendments.--
       (1) Section 1833(m) of such Act (42 U.S.C. 1395l(m)) is 
     amended by redesignating paragraph (4) as paragraph (5) and 
     by inserting after paragraph (3) the following new paragraph:
       ``(4) The provisions of this subsection shall not be taken 
     into account in applying subsections (m) or (u) and any 
     payment under such subsections shall not be taken into 
     account in computing payments under this subsection.''.
       (2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-
     4(m)(5)(B)) is amended by inserting ``, (p),'' after ``(m)''.
       (3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-
     4(o)(1)(B)(iv)) is amended by inserting ``primary care'' 
     before ``health professional shortage area''.

     SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-
                   MIDWIVES.

       (a) In General.--Section 1833(a)(1)(K) of the Social 
     Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by striking 
     ``(but in no event'' and all that follows through ``performed 
     by a physician)''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to services furnished on or after January 1, 
     2011.

     SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE 
                   SERVICES.

       (a) Medicare Covered Preventive Services Defined.--Section 
     1861 of the Social Security Act (42 U.S.C. 1395x), as amended 
     by section 1233(a)(1)(B), is amended by adding at the end the 
     following new subsection:

                 ``Medicare Covered Preventive Services

       ``(iii)(1) Subject to the succeeding provisions of this 
     subsection, the term `Medicare covered preventive services' 
     means the following:
       ``(A) Prostate cancer screening tests (as defined in 
     subsection (oo)).
       ``(B) Colorectal cancer screening tests (as defined in 
     subsection (pp).

[[Page 27292]]

       ``(C) Diabetes outpatient self-management training services 
     (as defined in subsection (qq)).
       ``(D) Screening for glaucoma for certain individuals (as 
     described in subsection (s)(2)(U)).
       ``(E) Medical nutrition therapy services for certain 
     individuals (as described in subsection (s)(2)(V)).
       ``(F) An initial preventive physical examination (as 
     defined in subsection (ww)).
       ``(G) Cardiovascular screening blood tests (as defined in 
     subsection (xx)(1)).
       ``(H) Diabetes screening tests (as defined in subsection 
     (yy)).
       ``(I) Ultrasound screening for abdominal aortic aneurysm 
     for certain individuals (as described in subsection 
     (s)(2)(AA)).
       ``(J) Federally approved and recommended vaccines and their 
     administration as described in subsection (s)(10).
       ``(K) Screening mammography (as defined in subsection 
     (jj)).
       ``(L) Screening pap smear and screening pelvic exam (as 
     defined in subsection (nn)).
       ``(M) Bone mass measurement (as defined in subsection 
     (rr)).
       ``(N) Kidney disease education services (as defined in 
     subsection (ggg)).
       ``(O) Additional preventive services (as defined in 
     subsection (ddd)).
       ``(2) With respect to specific Medicare covered preventive 
     services, the limitations and conditions described in the 
     provisions referenced in paragraph (1) with respect to such 
     services shall apply.''.
       (b) Payment and Elimination of Cost-sharing.--
       (1) In general.--
       (A) In general.--Section 1833(a) of the Social Security Act 
     (42 U.S.C. 1395l(a)) is amended by adding after and below 
     paragraph (9) the following:
     ``With respect to Medicare covered preventive services, in 
     any case in which the payment rate otherwise provided under 
     this part is computed as a percent of less than 100 percent 
     of an actual charge, fee schedule rate, or other rate, such 
     percentage shall be increased to 100 percent.''.
       (B) Application to sigmoidoscopies and colonoscopies.--
     Section 1834(d) of such Act (42 U.S.C. 1395m(d)) is amended--
       (i) in paragraph (2)(C), by amending clause (ii) to read as 
     follows:
       ``(ii) No coinsurance.--In the case of a beneficiary who 
     receives services described in clause (i), there shall be no 
     coinsurance applied.''; and
       (ii) in paragraph (3)(C), by amending clause (ii) to read 
     as follows:
       ``(ii) No coinsurance.--In the case of a beneficiary who 
     receives services described in clause (i), there shall be no 
     coinsurance applied.''.
       (2) Elimination of coinsurance in outpatient hospital 
     settings.--
       (A) Exclusion from opd fee schedule.--Section 
     1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
     1395l(t)(1)(B)(iv)) is amended by striking ``screening 
     mammography (as defined in section 1861(jj)) and diagnostic 
     mammography'' and inserting ``diagnostic mammograms and 
     Medicare covered preventive services (as defined in section 
     1861(iii)(1))''.
       (B) Conforming amendments.--Section 1833(a)(2) of the 
     Social Security Act (42 U.S.C. 1395l(a)(2)) is amended--
       (i) in subparagraph (F), by striking ``and'' after the 
     semicolon at the end;
       (ii) in subparagraph (G), by adding ``and'' at the end; and
       (iii) by adding at the end the following new subparagraph:
       ``(H) with respect to additional preventive services (as 
     defined in section 1861(ddd)) furnished by an outpatient 
     department of a hospital, the amount determined under 
     paragraph (1)(W);''.
       (3) Waiver of application of deductible for all preventive 
     services.--The first sentence of section 1833(b) of the 
     Social Security Act (42 U.S.C. 1395l(b)) is amended--
       (A) in clause (1), by striking ``items and services 
     described in section 1861(s)(10)(A)'' and inserting 
     ``Medicare covered preventive services (as defined in section 
     1861(iii))'';
       (B) by inserting ``and'' before ``(4)''; and
       (C) by striking clauses (5) through (8).
       (4) Application to providers of services.--Section 
     1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii)) 
     is amended by inserting ``other than for Medicare covered 
     preventive services and'' after ``for such items and services 
     (''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2011.
       (d) Preventive Services.--
       (1) Report to congress on barriers to preventive 
     services.--Not later than 12 months after the date of the 
     enactment of this Act, the Secretary of Health and Human 
     Services shall report to Congress on barriers, if any, facing 
     Medicare beneficiaries in accessing the benefit to abdominal 
     aortic aneurysm screening and other preventative services 
     through the Welcome to Medicare Physical Exam.
       (2) Abdominal aortic aneurysm screen access.--The Secretary 
     shall, to the extent practical, identify and implement 
     policies promoting proper use of abdominal aortic aneurysm 
     screening among Medicare beneficiaries at risk for such 
     aneurysms.

     SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER 
                   SCREENING TESTS REGARDLESS OF CODING, 
                   SUBSEQUENT DIAGNOSIS, OR ANCILLARY TISSUE 
                   REMOVAL.

       (a) In General.--Section 1833 of the Social Security Act 
     (42 U.S.C. 1395l(b)), as amended by section 1305(b), is 
     further amended--
       (1) in subsection (a), in the sentence added by section 
     1305(b)(1)(A), by inserting ``(including services described 
     in the last sentence of section 1833(b))'' after ``preventive 
     services''; and
       (2) in subsection (b), by adding at the end the following 
     new sentence: ``Clause (1) of the first sentence of this 
     subsection shall apply with respect to a colorectal cancer 
     screening test regardless of the code that is billed for the 
     establishment of a diagnosis as a result of the test, or for 
     the removal of tissue or other matter or other procedure that 
     is furnished in connection with, as a result of, and in the 
     same clinical encounter as, the screening test.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to items and services furnished on or after 
     January 1, 2011.

     SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM 
                   COVERAGE UNDER THE MEDICARE SKILLED NURSING 
                   FACILITY PROSPECTIVE PAYMENT SYSTEM AND 
                   CONSOLIDATED PAYMENT.

       (a) In General.--Section 1888(e)(2)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by 
     inserting ``clinical social worker services,'' after 
     ``qualified psychologist services,''.
       (b) Conforming Amendment.--Section 1861(hh)(2) of the 
     Social Security Act (42 U.S.C. 1395x(hh)(2)) is amended by 
     striking ``and other than services furnished to an inpatient 
     of a skilled nursing facility which the facility is required 
     to provide as a requirement for participation''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     October 1, 2010.

     SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES 
                   AND MENTAL HEALTH COUNSELOR SERVICES.

       (a) Coverage of Marriage and Family Therapist Services.--
       (1) Coverage of services.--Section 1861(s)(2) of the Social 
     Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 
     1235, is amended--
       (A) in subparagraph (EE), by striking ``and'' at the end;
       (B) in subparagraph (FF), by adding ``and'' at the end; and
       (C) by adding at the end the following new subparagraph:
       ``(GG) marriage and family therapist services (as defined 
     in subsection (jjj));''.
       (2) Definition.--Section 1861 of the Social Security Act 
     (42 U.S.C. 1395x), as amended by sections 1233 and 1305, is 
     amended by adding at the end the following new subsection:

                ``Marriage and Family Therapist Services

       ``(jjj)(1) The term `marriage and family therapist 
     services' means services performed by a marriage and family 
     therapist (as defined in paragraph (2)) for the diagnosis and 
     treatment of mental illnesses, which the marriage and family 
     therapist is legally authorized to perform under State law 
     (or the State regulatory mechanism provided by State law) of 
     the State in which such services are performed, as would 
     otherwise be covered if furnished by a physician or as 
     incident to a physician's professional service, but only if 
     no facility or other provider charges or is paid any amounts 
     with respect to the furnishing of such services.
       ``(2) The term `marriage and family therapist' means an 
     individual who--
       ``(A) possesses a master's or doctoral degree which 
     qualifies for licensure or certification as a marriage and 
     family therapist pursuant to State law;
       ``(B) after obtaining such degree has performed at least 2 
     years of clinical supervised experience in marriage and 
     family therapy; and
       ``(C) is licensed or certified as a marriage and family 
     therapist in the State in which marriage and family therapist 
     services are performed.''.
       (3) Provision for payment under part b.--Section 
     1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
     1395k(a)(2)(B)) is amended by adding at the end the following 
     new clause:
       ``(v) marriage and family therapist services;''.
       (4) Amount of payment.--
       (A) In general.--Section 1833(a)(1) of the Social Security 
     Act (42 U.S.C. 1395l(a)(1)) is amended--
       (i) by striking ``and'' before ``(W)''; and
       (ii) by inserting before the semicolon at the end the 
     following: ``, and (X) with respect to marriage and family 
     therapist services under section 1861(s)(2)(GG), the amounts 
     paid shall be 80 percent of the lesser of the actual charge 
     for the services or 75 percent of the amount determined for 
     payment of a psychologist under clause (L)''.
       (B) Development of criteria with respect to consultation 
     with a health care professional.--The Secretary of Health and 
     Human Services shall, taking into consideration concerns for 
     patient confidentiality, develop criteria with respect to 
     payment for marriage and family therapist services for

[[Page 27293]]

     which payment may be made directly to the marriage and family 
     therapist under part B of title XVIII of the Social Security 
     Act (42 U.S.C. 1395j et seq.) under which such a therapist 
     must agree to consult with a patient's attending or primary 
     care physician or nurse practitioner in accordance with such 
     criteria.
       (5) Exclusion of marriage and family therapist services 
     from skilled nursing facility prospective payment system.--
     Section 1888(e)(2)(A)(ii) of the Social Security Act (42 
     U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 1307(a), 
     is amended by inserting ``marriage and family therapist 
     services (as defined in subsection (jjj)(1)),'' after 
     ``clinical social worker services,''.
       (6) Coverage of marriage and family therapist services 
     provided in rural health clinics and federally qualified 
     health centers.--Section 1861(aa)(1)(B) of the Social 
     Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by 
     striking ``or by a clinical social worker (as defined in 
     subsection (hh)(1)),'' and inserting ``, by a clinical social 
     worker (as defined in subsection (hh)(1)), or by a marriage 
     and family therapist (as defined in subsection (jjj)(2)),''.
       (7) Inclusion of marriage and family therapists as 
     practitioners for assignment of claims.--Section 
     1842(b)(18)(C) of the Social Security Act (42 U.S.C. 
     1395u(b)(18)(C)) is amended by adding at the end the 
     following new clause:
       ``(vii) A marriage and family therapist (as defined in 
     section 1861(jjj)(2)).''.
       (b) Coverage of Mental Health Counselor Services.--
       (1) Coverage of services.--Section 1861(s)(2) of the Social 
     Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, 
     is further amended--
       (A) in subparagraph (FF), by striking ``and'' at the end;
       (B) in subparagraph (GG), by inserting ``and'' at the end; 
     and
       (C) by adding at the end the following new subparagraph:
       ``(HH) mental health counselor services (as defined in 
     subsection (kkk)(1));''.
       (2) Definition.--Section 1861 of the Social Security Act 
     (42 U.S.C. 1395x), as previously amended, is amended by 
     adding at the end the following new subsection:

                   ``Mental Health Counselor Services

       ``(kkk)(1) The term `mental health counselor services' 
     means services performed by a mental health counselor (as 
     defined in paragraph (2)) for the diagnosis and treatment of 
     mental illnesses which the mental health counselor is legally 
     authorized to perform under State law (or the State 
     regulatory mechanism provided by the State law) of the State 
     in which such services are performed, as would otherwise be 
     covered if furnished by a physician or as incident to a 
     physician's professional service, but only if no facility or 
     other provider charges or is paid any amounts with respect to 
     the furnishing of such services.
       ``(2) The term `mental health counselor' means an 
     individual who--
       ``(A) possesses a master's or doctor's degree which 
     qualifies the individual for licensure or certification for 
     the practice of mental health counseling in the State in 
     which the services are performed;
       ``(B) after obtaining such a degree has performed at least 
     2 years of supervised mental health counselor practice; and
       ``(C) is licensed or certified as a mental health counselor 
     or professional counselor by the State in which the services 
     are performed.''.
       (3) Provision for payment under part b.--Section 
     1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
     1395k(a)(2)(B)), as amended by subsection (a)(3), is further 
     amended--
       (A) by striking ``and'' at the end of clause (iv);
       (B) by adding ``and'' at the end of clause (v); and
       (C) by adding at the end the following new clause:
       ``(vi) mental health counselor services;''.
       (4) Amount of payment.--
       (A) In general.--Section 1833(a)(1) of the Social Security 
     Act (42 U.S.C. 1395l(a)(1)), as amended by subsection (a), is 
     further amended--
       (i) by striking ``and'' before ``(X)''; and
       (ii) by inserting before the semicolon at the end the 
     following: ``, and (Y), with respect to mental health 
     counselor services under section 1861(s)(2)(HH), the amounts 
     paid shall be 80 percent of the lesser of the actual charge 
     for the services or 75 percent of the amount determined for 
     payment of a psychologist under clause (L)''.
       (B) Development of criteria with respect to consultation 
     with a physician.--The Secretary of Health and Human Services 
     shall, taking into consideration concerns for patient 
     confidentiality, develop criteria with respect to payment for 
     mental health counselor services for which payment may be 
     made directly to the mental health counselor under part B of 
     title XVIII of the Social Security Act (42 U.S.C. 1395j et 
     seq.) under which such a counselor must agree to consult with 
     a patient's attending or primary care physician in accordance 
     with such criteria.
       (5) Exclusion of mental health counselor services from 
     skilled nursing facility prospective payment system.--Section 
     1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
     1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and 
     subsection (a), is amended by inserting ``mental health 
     counselor services (as defined in section 1861(kkk)(1)),'' 
     after ``marriage and family therapist services (as defined in 
     subsection (jjj)(1)),''.
       (6) Coverage of mental health counselor services provided 
     in rural health clinics and federally qualified health 
     centers.--Section 1861(aa)(1)(B) of the Social Security Act 
     (42 U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is 
     amended by striking ``or by a marriage and family therapist 
     (as defined in subsection (jjj)(2)),'' and inserting ``by a 
     marriage and family therapist (as defined in subsection 
     (jjj)(2)), or a mental health counselor (as defined in 
     subsection (kkk)(2)),''.
       (7) Inclusion of mental health counselors as practitioners 
     for assignment of claims.--Section 1842(b)(18)(C) of the 
     Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended 
     by subsection (a)(7), is amended by adding at the end the 
     following new clause:
       ``(viii) A mental health counselor (as defined in section 
     1861(kkk)(2)).''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after 
     January 1, 2011.

     SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH 
                   ADD-ON.

       Section 138(a)(1) of the Medicare Improvements for Patients 
     and Providers Act of 2008 (Public Law 110-275) is amended by 
     striking ``December 31, 2009'' and inserting ``December 31, 
     2011''.

     SEC. 1310. EXPANDING ACCESS TO VACCINES.

       (a) In General.--Paragraph (10) of section 1861(s) of the 
     Social Security Act (42 U.S.C. 1395w(s)) is amended to read 
     as follows:
       ``(10) federally approved and recommended vaccines (as 
     defined in subsection (lll)) and their respective 
     administration;''.
       (b) Federally Approved and Recommended Vaccines Defined.--
     Section 1861 of such Act is further amended by adding at the 
     end the following new subsection:

             ``Federally Approved and Recommended Vaccines

       ``(lll) The term `federally approved and recommended 
     vaccine' means a vaccine that--
       ``(1) is licensed under section 351 of the Public Health 
     Service Act, approved under the Federal Food, Drug, and 
     Cosmetic Act, or authorized for emergency use under section 
     564 of the Federal, Food, Drug, and Cosmetic Act; and
       ``(2) is recommended by the Director of the Centers for 
     Disease Control and Prevention.''.
       (c) Conforming Amendments.--
       (1) Section 1833 of such Act (42 U.S.C. 1395l) is amended, 
     in each of subsections (a)(1)(B), (a)(2)(G), and (a)(3)(A), 
     by striking ``1861(s)(10)(A)'' and inserting ``1861(s)(10)'' 
     each place it appears.
       (2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C. 
     1395u(o)(1)(A)(iv)) is amended--
       (A) by striking ``subparagraph (A) or (B) of''; and
       (B) by inserting before the period the following: ``and 
     before January 1, 2011, and influenza vaccines furnished on 
     or after January 1, 2011''.
       (3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-
     3a(c)(6)) is amended--
       (A) in subparagraph (D)(i), by inserting ``, including a 
     vaccine furnished on or after January 1, 2010''; and
       (B) by the following new paragraph:
       ``(H) Implementation.--Chapter 35 of title 44, United 
     States Code shall not apply to manufacturer provision of 
     information pursuant to section 1927(b)(3)(A)(iii) or 
     subsection (f)(2) for purposes of implementation of this 
     section.''.
       (4) Section 1860D-2(e)(1) of such Act (42 U.S.C. 1395w-
     102(e)(1)) is amended by striking ``such term includes a 
     vaccine'' and all that follows through ``its administration) 
     and''.
       (5) Section 1861(ww)(2)(A) of such Act (42 U.S.C. 
     1395x(ww)(2)(A))) is amended by striking ``Pneumococcal, 
     influenza, and hepatitis B vaccine and administration'' and 
     inserting ``federally approved or authorized vaccines (as 
     defined in subsection (lll)) and their respective 
     administration''.
       (6) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C. 
     1396r-8(b)(3)(A)(iii)) is amended, in the matter following 
     subclause (III), by inserting ``(A)(iv) (including influenza 
     vaccines furnished on or after January 1, 2011),'' after 
     ``described in subparagraph''.
       (7) Section 1847A(f) of such Act (42 U.S.C. 1395w-3a(f)) is 
     amended--
       (A) by striking ``For'' and inserting ``(1) In general.--
     For'';
       (B) by indenting paragraph (1), as redesignated in 
     subparagraph (A), 2 ems to the left; and--
       (C) by adding at the end the following new paragraph:
       ``(2) Treatment of certain manufacturers.--In the case of a 
     manufacturer of a drug or biological described in 
     subparagraphs (A)(iv), (C), (D), (E), or (G) of section 
     1842(o)(1) that does not have a rebate agreement under 
     section 1927(a), no payment may be made under this part for 
     such drug or biological if such manufacturer does not submit 
     the information described in section 1927(b)(3)(A)(iii) in 
     the same manner as if the manufacturer had such a rebate 
     agreement

[[Page 27294]]

     in effect. Subparagraphs (C) and (D) of section 1927(b)(3) 
     shall apply to information reported pursuant to the previous 
     sentence in the same manner as such subparagraphs apply with 
     respect to information reported pursuant to such 
     section.''.''.
       (d) Effective Dates.--The amendments made--
       (1) by this section (other than by subsection (c)(6)) shall 
     apply to vaccines administered on or after January 1, 2011; 
     and
       (2) by subsection (c)(6) shall apply to calendar quarters 
     beginning on or after January 1, 2010.

     SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES 
                   AT FEDERALLY QUALIFIED HEALTH CENTERS.

       (a) In General.--Section 1861(aa)(3)(A) of the Social 
     Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read 
     as follows:
       ``(A) services of the type described subparagraphs (A) 
     through (C) of paragraph (1) and services described in 
     section 1861(iii); and''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply not later than January 1, 2011.

     SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.

       Title XVIII of the Social Security Act is amended by 
     inserting after section 1866F, as inserted by section 1302, 
     the following new section:


     ``independence at home medical practice demonstration program

       ``Sec. 1866G.  (a) Establishment.--
       ``(1) In general.--The Secretary shall conduct a 
     demonstration program (in this section referred to as the 
     `demonstration program') to test a payment incentive and 
     service delivery model that utilizes physician and nurse 
     practitioner directed home-based primary care teams designed 
     to reduce expenditures and improve health outcomes in the 
     provision of items and services under this title to 
     applicable beneficiaries (as defined in subsection (d)).
       ``(2) Requirement.--The demonstration program shall test 
     whether a model described in paragraph (1), which is 
     accountable for providing comprehensive, coordinated, 
     continuous, and accessible care to high-need populations at 
     home and coordinating health care across all treatment 
     settings, results in--
       ``(A) reducing preventable hospitalizations;
       ``(B) preventing hospital readmissions;
       ``(C) reducing emergency room visits;
       ``(D) improving health outcomes commensurate with the 
     beneficiaries' stage of chronic illness;
       ``(E) improving the efficiency of care, such as by reducing 
     duplicative diagnostic and laboratory tests;
       ``(F) reducing the cost of health care services covered 
     under this title; and
       ``(G) achieving beneficiary and family caregiver 
     satisfaction.
       ``(b) Independence at Home Medical Practice.--
       ``(1) Independence at home medical practice defined.--In 
     this section:
       ``(A) In general.--The term `independence at home medical 
     practice' means a legal entity that--
       ``(i) is comprised of an individual physician or nurse 
     practitioner or group of physicians and nurse practitioners 
     that provides care as part of a team that includes 
     physicians, nurses, physician assistants, pharmacists, and 
     other health and social services staff as appropriate who 
     have experience providing home-based primary care to 
     applicable beneficiaries, make in-home visits, and are 
     available 24 hours per day, 7 days per week to carry out 
     plans of care that are tailored to the individual 
     beneficiary's chronic conditions and designed to achieve the 
     results in subsection (a);
       ``(ii) is organized at least in part for the purpose of 
     providing physicians' services;
       ``(iii) has documented experience in providing home-based 
     primary care services to high cost chronically ill 
     beneficiaries, as determined appropriate by the Secretary;
       ``(iv) includes at least 200 applicable beneficiaries as 
     defined in subsection (d);
       ``(v) has entered into an agreement with the Secretary;
       ``(vi) uses electronic health information systems, remote 
     monitoring, and mobile diagnostic technology; and
       ``(vii) meets such other criteria as the Secretary 
     determines to be appropriate to participate in the 
     demonstration program.
       ``(B) Physician.--The term `physician' includes, except as 
     the Secretary may otherwise provide, any individual who 
     furnishes services for which payment may be made as 
     physicians' services and has the medical training or 
     experience to fulfill the physician's role described in 
     subparagraph (A)(i).
       ``(2) Participation of nurse practitioners and physician 
     assistants.--Nothing in this section shall be construed to 
     prevent a nurse practitioner or physician assistant from 
     participating in, or leading, a home-based primary care team 
     as part of an independence at home medical practice if--
       ``(A) all the requirements of this section are met;
       ``(B) the nurse practitioner or physician assistant, as the 
     case may be, is acting consistent with State law; and
       ``(C) the nurse practitioner or physician assistant has the 
     medical training or experience to fulfill the nurse 
     practitioner or physician assistant role described in 
     paragraph (1)(A)(i).
       ``(3) Inclusion of providers and practitioners.--Nothing in 
     this subsection shall be construed as preventing an 
     independence at home medical practice from including a 
     provider of services or a participating practitioner 
     described in section 1842(b)(18)(C) that is affiliated with 
     the practice under an arrangement structured so that such 
     provider of services or practitioner participates in the 
     demonstration program and shares in any savings under the 
     demonstration program.
       ``(4) Quality and performance standards.--
       ``(A) In general.--An independence at home medical practice 
     participating in the demonstration program shall report on 
     quality measures (in such form, manner, and frequency as 
     specified by the Secretary, which may be for the group, for 
     providers of services and suppliers, or both) and report to 
     the Secretary (in a form, manner, and frequency as specified 
     by the Secretary) such data as the Secretary determines 
     appropriate to monitor and evaluate the demonstration 
     program.
       ``(B) Development of quality performance standards.--The 
     Secretary shall develop quality performance standards for 
     independence at home medical practices participating in the 
     demonstration program.
       ``(c) Shared Savings Payment Methodology.--
       ``(1) Establishment of target spending level.--The 
     Secretary shall establish annual target spending levels for 
     items and services covered under parts A and B furnished to 
     applicable beneficiaries by qualifying independence at home 
     medical practices under this section. The Secretary may set 
     an aggregate target spending level for all qualifying 
     practices, or may set different target spending levels for 
     groups of practices or a single practice. Such target 
     spending levels may be determined on a per capita basis and 
     shall take into account normal variation in expenditures for 
     items and services covered under parts A and B furnished to 
     such beneficiaries. The target shall also be adjusted for the 
     size of the practice, number of practices included in the 
     target spending level, characteristics of applicable 
     beneficiaries and such other factors as the Secretary 
     determines appropriate. The Secretary may periodically adjust 
     or rebase the target spending level under this paragraph.
       ``(2) Shared savings amounts.--
       ``(A) In general.--Subject to subparagraph (B), qualifying 
     independence at home medical practices are eligible to 
     receive an incentive payment under this section if aggregate 
     expenditures for a year for applicable beneficiaries are less 
     than the target spending level for qualifying independence at 
     home medical practices for such year. An incentive payment 
     for such year shall be equal to a portion (as determined by 
     the Secretary) of the amount by which total payments for 
     applicable beneficiaries under parts A and B for such year 
     are estimated to be less than 5 percent less than the target 
     spending level for such year, as determined by the Secretary.
       ``(B) Apportionment of savings.--The Secretary shall 
     designate how, and to what extent, an incentive payment under 
     this section is to be apportioned among qualifying 
     independence at home medical practices, taking into account 
     the size of the practice, characteristics of the individuals 
     enrolled in each practice, performance on quality performance 
     measures, and such other factors as the Secretary determines 
     appropriate.
       ``(3) Savings to the medicare program.--The Secretary shall 
     limit incentive payments to each qualifying independence at 
     home medical practice under this paragraph, with respect to a 
     year, as necessary to ensure that the aggregate expenditures 
     for items and services under parts A and B with respect to 
     applicable beneficiaries for such independence at home 
     medical practice (inclusive of shared savings payments) do 
     not exceed the amount that the Secretary estimates would be 
     expended for such items and services for such beneficiaries 
     during such year (taking into account normal variation in 
     expenditures and other factors the Secretary deems 
     appropriate) if the demonstration program under this section 
     were not implemented, minus 5 percent.
       ``(d) Applicable Beneficiaries.--
       ``(1) Definition.--In this section, the term `applicable 
     beneficiary' means, with respect to a qualifying independence 
     at home medical practice, an individual who the practice has 
     determined--
       ``(A) is entitled to benefits under part A and enrolled for 
     benefits under part B;
       ``(B) is not enrolled in a Medicare Advantage plan under 
     part C or a PACE program under section 1894;
       ``(C) has 2 or more chronic illnesses, such as congestive 
     heart failure, diabetes, other dementias designated by the 
     Secretary, chronic obstructive pulmonary disease, ischemic 
     heart disease, stroke, Alzheimer's Disease and 
     neurodegenerative diseases, and other diseases and conditions 
     designated by the Secretary which result in high costs under 
     this title;
       ``(D) within the past 12 months has had a nonelective 
     hospital admission;
       ``(E) within the past 12 months has received acute or 
     subacute rehabilitation services;

[[Page 27295]]

       ``(F) has 2 or more functional dependencies requiring the 
     assistance of another person (such as bathing, dressing, 
     toileting, walking, or feeding); and
       ``(G) meets such other criteria as the Secretary determines 
     appropriate.
       ``(2) Patient election to participate.--The Secretary shall 
     determine an appropriate method of ensuring that applicable 
     beneficiaries have agreed to enroll in an independence at 
     home medical practice under the demonstration program. 
     Enrollment in the demonstration program shall be voluntary.
       ``(3) Beneficiary access to services.--Nothing in this 
     section shall be construed as encouraging physicians or nurse 
     practitioners to limit applicable beneficiary access to 
     services covered under this title and applicable 
     beneficiaries shall not be required to relinquish access to 
     any benefit under this title as a condition of receiving 
     services from an independence at home medical practice.
       ``(e) Implementation.--
       ``(1) Starting date.--The demonstration program shall begin 
     not later than January 1, 2012. An agreement with an 
     independence at home medical practice under the demonstration 
     program may cover not more than a 3-year period.
       ``(2) No physician duplication in demonstration 
     participation.--The Secretary shall not pay an independence 
     at home medical practice under this section that participates 
     in section 1866D or section 1866E.
       ``(3) No beneficiary duplication in demonstration 
     participation.--The Secretary shall ensure that no applicable 
     beneficiary enrolled in an independence at home medical 
     practice under this section is participating in the programs 
     under section 1866D or section 1866E.
       ``(4) Preference.--In approving an independence at home 
     medical practice, the Secretary shall give preference to 
     practices that are--
       ``(A) located in high-cost areas of the country;
       ``(B) have experience in furnishing health care services to 
     applicable beneficiaries in the home; and
       ``(C) use electronic medical records, health information 
     technology, and individualized plans of care.
       ``(5) Number of practices.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary shall enter into agreements with as many 
     independence at home medial practices as practicable and 
     consistent with this subsection to test the potential of the 
     independence at home medical practice model under this 
     section in order to achieve the results described in 
     subsection (a) across practices serving varying numbers of 
     applicable beneficiaries.
       ``(B) Limitation.--In selecting qualified independence at 
     home medial practices to participate under the demonstration 
     program, the Secretary shall limit the number of applicable 
     beneficiaries that may participate in the demonstration 
     program to 10,000.
       ``(6) Waiver.--The Secretary may waive such provisions of 
     this title and title XI as the Secretary determines necessary 
     in order to implement the demonstration program.
       ``(7) Administration.--Chapter 35 of title 44, United 
     States Code, shall not apply to this section.
       ``(f) Evaluation and Monitoring.--
       ``(1) In general.--The Secretary shall evaluate each 
     independence at home medical practice under the demonstration 
     program to assess whether the practice achieved the results 
     described in subsection (a).
       ``(2) Following applicable beneficiaries.--The Secretary 
     may monitor data on expenditures and quality of services 
     under this title after an applicable beneficiary discontinues 
     receiving services under this title through a qualifying 
     independence at home medical practice.
       ``(g) Reports to Congress.--The Secretary shall conduct an 
     independent evaluation of the demonstration program and 
     submit to Congress a final report, including best practices 
     under the demonstration program. Such report shall include an 
     analysis of the demonstration program on coordination of 
     care, expenditures under this title, applicable beneficiary 
     access to services, and the quality of health care services 
     provided to applicable beneficiaries.
       ``(h) Funding.--For purposes of administering and carrying 
     out the demonstration program, other than for payments for 
     items and services furnished under this title and shared 
     savings under subsection (c), in addition to funds otherwise 
     appropriated, there shall be transferred to the Secretary for 
     the Center for Medicare & Medicaid Services Program 
     Management Account from the Federal Hospital Insurance Trust 
     Fund under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841 $5,000,000 for each 
     of fiscal years 2010 through 2015. Amounts transferred under 
     this subsection for a fiscal year shall be available until 
     expended.
       ``(i) Antidiscrimination Limitation.--The Secretary shall 
     not enter into an agreement with an entity to provide health 
     care items or services under the demonstration program unless 
     such entity guarantees that for individuals eligible to be 
     enrolled in such program, the entity will not deny, limit, or 
     condition the coverage or provision of benefits to which the 
     individual would have otherwise been entitled to on the basis 
     of health status if not included in this program.
       ``(j) Termination.--The Secretary may terminate an 
     agreement with an independence at home medical practice if 
     such practice does not receive incentive payments under 
     subsection (c)(2) or consistently fails to meet quality 
     standards.''.

     SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDUCATORS AS 
                   CERTIFIED PROVIDERS FOR PURPOSES OF MEDICARE 
                   DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING 
                   SERVICES.

       (a) In General.--Section 1861(qq) of the Social Security 
     Act (42 U.S.C. 1395x(qq)) is amended--
       (1) in paragraph (1), by inserting ``or by a certified 
     diabetes educator (as defined in paragraph (3))'' after 
     ``paragraph (2)(B)''; and
       (2) by adding at the end the following new paragraphs:
       ``(3) For purposes of paragraph (1), the term `certified 
     diabetes educator' means an individual who--
       ``(A) is licensed or registered by the State in which the 
     services are performed as a health care professional;
       ``(B) specializes in teaching individuals with diabetes to 
     develop the necessary skills and knowledge to manage the 
     individual's diabetic condition; and
       ``(C) is certified as a diabetes educator by a recognized 
     certifying body (as defined in paragraph (4)).
       ``(4)(A) For purposes of paragraph (3)(C), the term 
     `recognized certifying body' means--
       ``(i) the National Certification Board for Diabetes 
     Educators, or
       ``(ii) a certifying body for diabetes educators, which is 
     recognized by the Secretary as authorized to grant 
     certification of diabetes educators for purposes of this 
     subsection pursuant to standards established by the 
     Secretary, if the Secretary determines such Board or body, 
     respectively, meets the requirement of subparagraph (B).
       ``(B) The National Certification Board for Diabetes 
     Educators or a certifying body for diabetes educators meets 
     the requirement of this subparagraph, with respect to the 
     certification of an individual, if the Board or body, 
     respectively, is incorporated and registered to do business 
     in the United States and requires as a condition of such 
     certification each of the following:
       ``(i) The individual has a qualifying credential in a 
     specified health care profession.
       ``(ii) The individual has professional practice experience 
     in diabetes self-management training that includes a minimum 
     number of hours and years of experience in such training.
       ``(iii) The individual has successfully completed a 
     national certification examination offered by such entity.
       ``(iv) The individual periodically renews certification 
     status following initial certification.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to diabetes outpatient self-management training 
     services furnished on or after the first day of the first 
     calendar year that is at least 6 months after the date of the 
     enactment of this Act.

                           TITLE IV--QUALITY

             Subtitle A--Comparative Effectiveness Research

     SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.

       (a) In General.--Title XI of the Social Security Act is 
     amended by adding at the end the following new part:

              ``Part D--Comparative Effectiveness Research


                  ``comparative effectiveness research

       ``Sec. 1181.  (a) Center for Comparative Effectiveness 
     Research Established.--
       ``(1) In general.--The Secretary shall establish within the 
     Agency for Healthcare Research and Quality a Center for 
     Comparative Effectiveness Research (in this section referred 
     to as the `Center') to conduct, support, and synthesize 
     research (including research conducted or supported under 
     section 1013 of the Medicare Prescription Drug, Improvement, 
     and Modernization Act of 2003) with respect to the outcomes, 
     effectiveness, and appropriateness of health care services 
     and procedures in order to identify the manner in which 
     diseases, disorders, and other health conditions can most 
     effectively and appropriately be prevented, diagnosed, 
     treated, and managed clinically.
       ``(2) Duties.--The Center shall--
       ``(A) conduct, support, and synthesize research relevant to 
     the comparative effectiveness of the full spectrum of health 
     care items, services and systems, including pharmaceuticals, 
     medical devices, medical and surgical procedures, and other 
     medical interventions;
       ``(B) conduct and support systematic reviews of clinical 
     research, including original research conducted subsequent to 
     the date of the enactment of this section;
       ``(C) continuously develop rigorous scientific 
     methodologies for conducting comparative effectiveness 
     studies, and use such methodologies appropriately;
       ``(D) submit to the Comparative Effectiveness Research 
     Commission, the Secretary, and Congress appropriate relevant 
     reports described in subsection (d)(2);

[[Page 27296]]

       ``(E) not later than one year after the date of the 
     enactment of this section, enter into an arrangement under 
     which the Institute of Medicine of the National Academy of 
     Sciences shall conduct an evaluation and report on standards 
     of evidence for highly credible research;
       ``(F) encourage, as appropriate, the development and use of 
     clinical registries and the development of clinical 
     effectiveness research data networks from electronic health 
     records, post marketing drug and medical device surveillance 
     efforts, and other forms of electronic health data; and
       ``(G) appoint clinical perspective advisory panels for 
     research priorities under this section, which shall consult 
     with patients and other stakeholders and advise the Center on 
     research questions, methods, and evidence gaps in terms of 
     clinical outcomes for the specific research inquiry to be 
     examined with respect to such priority to ensure that the 
     information produced from such research is clinically 
     relevant to decisions made by clinicians and patients at the 
     point of care.
       ``(3) Powers.--
       ``(A) Obtaining official data.--The Center may secure 
     directly from any department or agency of the United States 
     information necessary to enable it to carry out this section. 
     Upon request of the Center, the head of such department or 
     agency shall furnish that information to the Center on an 
     agreed upon schedule.
       ``(B) Data collection.--In order to carry out its 
     functions, the Center shall--
       ``(i) utilize existing information, both published and 
     unpublished, where possible, collected and assessed either by 
     its own staff or under other arrangements made in accordance 
     with this section;
       ``(ii) carry out, or award grants or contracts for, 
     original research and experimentation, where existing 
     information is inadequate; and
       ``(iii) adopt procedures allowing any interested party to 
     submit information for the use by the Center in making 
     reports and recommendations.
     In carrying out clause (ii), the Center may award grants or 
     contracts (or provide for intergovernmental transfers, as 
     applicable) to private entities and governmental agencies 
     with experience in conducting comparative effectiveness 
     research, such as the National Institutes of Health and other 
     relevant Federal health agencies.
       ``(C) Access of gao to information.--The Comptroller 
     General shall have unrestricted access to all deliberations, 
     records, and nonproprietary data of the Center and Commission 
     under subsection (b), immediately upon request.
       ``(D) Periodic audit.--The Center and Commission under 
     subsection (b) shall be subject to periodic audit by the 
     Comptroller General.
       ``(b) Comparative Effectiveness Research Commission.--
       ``(1) In general.--There is established an independent 
     Comparative Effectiveness Research Commission (in this 
     section referred to as the `Commission') to advise the Center 
     and evaluate the activities carried out by the Center under 
     subsection (a) to ensure such activities result in highly 
     credible research and information resulting from such 
     research.
       ``(2) Duties.--The Commission shall--
       ``(A)(i) recommend to the Center national priorities for 
     research described in subsection (a) which shall take into 
     account--
       ``(I) disease incidence, prevalence, and burden in the 
     United States;
       ``(II) evidence gaps in terms of clinical outcomes;
       ``(III) variations in practice, delivery, and outcomes by 
     geography, treatment site, provider type, disability, 
     variation in age group (including children, adolescents, 
     adults, and seniors), racial and ethnic background, gender, 
     genetic and molecular subtypes, and other appropriate 
     populations or subpopulations; and
       ``(IV) the potential for new evidence concerning certain 
     categories, health care services, or treatments to improve 
     patient health and well-being, and the quality of care; and
       ``(ii) in making such recommendations consult with a broad 
     array of public and private stakeholders, including patients 
     and health care providers and payers;
       ``(B) monitor the appropriateness of use of the CERTF 
     described in subsection (g) with respect to the timely 
     production of comparative effectiveness research recommended 
     to be a national priority under subparagraph (A);
       ``(C) identify highly credible research methods and 
     standards of evidence for such research to be considered by 
     the Center;
       ``(D) review the methodologies developed by the center 
     under subsection (a)(2)(C);
       ``(E) support forums to increase stakeholder awareness and 
     permit stakeholder feedback on the efforts of the Center to 
     advance methods and standards that promote highly credible 
     research;
       ``(F) make recommendations to the Center for policies that 
     would allow for public access of data produced under this 
     section, in accordance with appropriate privacy and 
     proprietary practices, while ensuring that the information 
     produced through such data is timely and credible;
       ``(G) make recommendations to the Center for the priority 
     for periodic reviews of previous comparative effectiveness 
     research and studies conducted by the Center under subsection 
     (a);
       ``(H) at least annually review the processes of the Center 
     and make reports to Congress and the President regarding 
     research conducted, supported, or synthesized by the Center 
     to confirm that the information produced by such research is 
     objective, credible, consistent with standards of evidence 
     developed under this section, and developed through a 
     transparent process that includes consultations with 
     appropriate stakeholders;
       ``(I) make recommendations to the Center for the broad 
     dissemination, consistent with subsection (e), of the 
     findings of research conducted and supported under this 
     section that enables clinicians, patients, consumers, and 
     payers to make more informed health care decisions that 
     improve quality and value; and
       ``(J) at least twice each year, hold a public meeting with 
     an opportunity for stakeholder input.
     The reports under subparagraph (H) shall not be submitted to 
     the Office of Management and Budget or to any other Federal 
     agency or executive department for any purpose prior to 
     transmittal to Congress and the President. Such reports shall 
     be published on the public internet website of the Commission 
     after the date of such transmittal.
       ``(3) Composition of commission.--
       ``(A) In general.--The members of the Commission shall 
     consist of--
       ``(i) the Director of the Agency for Healthcare Research 
     and Quality or their designee;
       ``(ii) the Chief Medical Officer of the Centers for 
     Medicare & Medicaid Services or their designee;
       ``(iii) the Director of the National Institutes of Health 
     or their designee; and
       ``(iv) 16 additional members who shall represent broad 
     constituencies of stakeholders including clinicians, 
     patients, researchers, third-party payers, and consumers of 
     Federal and State beneficiary programs.
     Of such members, at least 10 shall be practicing physicians, 
     health care practitioners, consumers, or patients.
       ``(B) Qualifications.--
       ``(i) Diverse representation of perspectives.--The members 
     of the Commission shall represent a broad range of 
     perspectives and shall collectively have experience in the 
     following areas:

       ``(I) Epidemiology.
       ``(II) Health services research.
       ``(III) Bioethics.
       ``(IV) Decision sciences.
       ``(V) Health disparities.
       ``(VI) Health economics.

       ``(ii) Diverse representation of health care community.--At 
     least one member shall represent each of the following health 
     care communities:

       ``(I) Patients.
       ``(II) Health care consumers.
       ``(III) Practicing Physicians, including surgeons.
       ``(IV) Other health care practitioners engaged in clinical 
     care.
       ``(V) Organizations with proven expertise in racial and 
     ethnic minority health research.
       ``(VI) Employers.
       ``(VII) Public payers.
       ``(VIII) Insurance plans.
       ``(IX) Clinical researchers who conduct research on behalf 
     of pharmaceutical or device manufacturers.

       ``(C) Limitation.--No more than 3 of the Members of the 
     Commission may be representatives of pharmaceutical or device 
     manufacturers and such representatives shall be clinical 
     researchers described under subparagraph (B)(ii)(IX).
       ``(4) Appointment.--The Comptroller General shall appoint 
     the members of the Commission.
       ``(5) Chairman; vice chairman.--The Comptroller General 
     shall designate a member of the Commission, at the time of 
     appointment of the member, as Chairman and a member as Vice 
     Chairman for that term of appointment, except that in the 
     case of vacancy of the Chairmanship or Vice Chairmanship, the 
     Comptroller General may designate another member for the 
     remainder of that member's term. The Chairman shall serve as 
     an ex officio member of the National Advisory Council of the 
     Agency for Health Care Research and Quality under section 
     931(c)(3)(B) of the Public Health Service Act.
       ``(6) Terms.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     each member of the Commission shall be appointed for a term 
     of 4 years.
       ``(B) Terms of initial appointees.--Of the members first 
     appointed--
       ``(i) 8 shall be appointed for a term of 4 years; and
       ``(ii) 8 shall be appointed for a term of 3 years.
       ``(7) Compensation.--While serving on the business of the 
     Commission (including travel time), a member of the 
     Commission shall be entitled to compensation at the per diem 
     equivalent of the rate provided for level IV of the Executive 
     Schedule under section 5315 of title 5, United States Code; 
     and while so serving away from home and the member's regular 
     place of business, a member may be

[[Page 27297]]

     allowed travel expenses, as authorized by the Director of the 
     Commission.
       ``(8) Director and staff; experts and consultants.--Subject 
     to such review as the Comptroller General deems necessary to 
     assure the efficient administration of the Commission, the 
     Commission may--
       ``(A) appoint and set the compensation for an Executive 
     Director (subject to the approval of the Comptroller General) 
     and such other personnel as Federal employees under section 
     2105 of title 5, United States Code, as may be necessary to 
     carry out its duties (without regard to the provisions of 
     title 5, United States Code, governing appointments in the 
     competitive service);
       ``(B) seek such assistance and support as may be required 
     in the performance of its duties from appropriate Federal 
     departments and agencies;
       ``(C) enter into contracts or make other arrangements, as 
     may be necessary for the conduct of the work of the 
     Commission (without regard to section 3709 of the Revised 
     Statutes (41 U.S.C. 5));
       ``(D) make advance, progress, and other payments which 
     relate to the work of the Commission;
       ``(E) provide transportation and subsistence for persons 
     serving without compensation; and
       ``(F) prescribe such rules and regulations as it deems 
     necessary with respect to the internal organization and 
     operation of the Commission.
       ``(9) Obtaining official data.--The Commission may secure 
     directly from any department or agency of the United States 
     information necessary to enable the Commission to carry out 
     this section. Upon request of the Chairman of the Commission, 
     the head of such department or agency shall furnish the 
     information to the Commission on an agreed upon schedule.
       ``(10) Availability of reports.--The Commission shall 
     transmit to the Secretary a copy of each report submitted 
     under this subsection and shall make such reports available 
     to the public.
       ``(11) Coordination.--To enhance effectiveness and 
     coordination, the Secretary is encouraged, to the greatest 
     extent possible, to seek coordination between the Commission 
     and the National Advisory Council of the Agency for 
     Healthcare Research and Quality.
       ``(12) Conflicts of interest.--
       ``(A) In general.--In appointing the members of the 
     Commission or a clinical perspective advisory panel described 
     in subsection (a)(2)(G), the Comptroller General or the 
     Secretary, respectively, shall take into consideration any 
     financial interest (as defined in subparagraph (D)), 
     consistent with this paragraph, and develop a plan for 
     managing any identified conflicts.
       ``(B) Evaluation and criteria.--When considering an 
     appointment to the Commission or a clinical perspective 
     advisory panel described subsection (a)(2)(G), the 
     Comptroller General or the Secretary, respectively, shall 
     review the expertise of the individual and the financial 
     disclosure report filed by the individual pursuant to the 
     Ethics in Government Act of 1978 for each individual under 
     consideration for the appointment, so as to reduce the 
     likelihood that an appointed individual will later require a 
     written determination as referred to in section 208(b)(1) of 
     title 18, United States Code, a written certification as 
     referred to in section 208(b)(3) of title 18, United States 
     Code, or a waiver as referred to in subparagraph (D)(iii) for 
     service on the Commission at a meeting of the Commission.
       ``(C) Disclosures; prohibitions on participation; 
     waivers.--
       ``(i) Disclosure of financial interest.--Prior to a meeting 
     of the Commission or a clinical perspective advisory panel 
     described in subsection (a)(2)(G) regarding a `particular 
     matter' (as that term is used in section 208 of title 18, 
     United States Code), each member of the Commission or the 
     clinical perspective advisory panel who is a full-time 
     Government employee or special Government employee shall 
     disclose to the Comptroller General or Secretary, 
     respectively, financial interests in accordance with 
     requiring a waiver under section 208(b) of title 18, United 
     States Code, or other interests as deemed relevant by the 
     Secretary.
       ``(ii) Prohibitions on participation.--Except as provided 
     under clause (iii), a member of the Commission or a clinical 
     perspective advisory panel described in subsection (a)(2)(G) 
     may not participate with respect to a particular matter 
     considered in meeting of the Commission or the clinical 
     perspective advisory panel if such member has a financial 
     interest that could be affected by the advice given to the 
     Secretary with respect to such matter, excluding interests 
     exempted in regulations issued by the Director of the Office 
     of Government Ethics as too remote or inconsequential to 
     affect the integrity of the services of the Government 
     officers or employees to which such regulations apply.
       ``(iii) Waiver.--If the Comptroller General or Secretary, 
     as applicable, determines it necessary to afford the 
     Commission or a clinical perspective advisory panel described 
     in subsection (a)(2)(G) essential expertise, the Comptroller 
     General or Secretary, respectively, may grant a waiver of the 
     prohibition in clause (ii) to permit a member described in 
     such subparagraph to--

       ``(I) participate as a non-voting member with respect to a 
     particular matter considered in a meeting of the Commission 
     or a clinical perspective advisory panel, respectively; or
       ``(II) participate as a voting member with respect to a 
     particular matter considered in a meeting of the Commission.

       ``(iv) Limitation on waivers and other exceptions.--

       ``(I) Determination of allowable exceptions for the 
     commission.--The number of waivers granted to members of the 
     Commission cannot exceed one-half of the total number of 
     members for the Commission.
       ``(II) Prohibition on voting status on clinical perspective 
     advisory panels.--No voting member of any clinical 
     perspective advisory panel shall be in receipt of a waiver. 
     No more than two nonvoting members of any clinical 
     perspective advisory panel shall receive a waiver.

       ``(D) Financial interest defined.--For purposes of this 
     paragraph, the term `financial interest' means a financial 
     interest under section 208(a) of title 18, United States 
     Code.
       ``(13) Application of faca.--The Federal Advisory Committee 
     Act (other than section 14 of such Act) shall apply to the 
     Commission to the extent that the provisions of such Act do 
     not conflict with the requirements of this subsection.
       ``(c) Research Requirements.--Any research conducted, 
     supported, or synthesized under this section shall meet the 
     following requirements:
       ``(1) Ensuring transparency, credibility, and access.--
       ``(A) The establishment of a research agenda by the Center 
     shall be informed by the national priorities for research 
     recommended under subsection (b)(2)(A).
       ``(B) The establishment of the agenda and conduct of the 
     research shall be insulated from inappropriate political or 
     stakeholder influence.
       ``(C) Methods of conducting such research shall be 
     scientifically based.
       ``(D) Consistent with applicable law, all aspects of the 
     prioritization of research, conduct of the research, and 
     development of conclusions based on the research shall be 
     transparent to all stakeholders.
       ``(E) Consistent with applicable law, the process and 
     methods for conducting such research shall be publicly 
     documented and available to all stakeholders.
       ``(F) Throughout the process of such research, the Center 
     shall provide opportunities for all stakeholders involved to 
     review and provide public comment on the methods and findings 
     of such research.
       ``(G) Such research shall consider advice given to the 
     Center by the clinical perspective advisory panel for the 
     particular national research priority.
       ``(2) Stakeholder input.--
       ``(A) In general.--The Commission shall consult with 
     patients, health care providers, health care consumer 
     representatives, and other appropriate stakeholders with an 
     interest in the research through a transparent process 
     recommended by the Commission.
       ``(B) Specific areas of consultation.--Consultation shall 
     include where deemed appropriate by the Commission--
       ``(i) recommending research priorities and questions;
       ``(ii) recommending research methodologies; and
       ``(iii) advising on and assisting with efforts to 
     disseminate research findings.
       ``(C) Ombudsman.--The Secretary shall designate a patient 
     ombudsman. The ombudsman shall--
       ``(i) serve as an available point of contact for any 
     patients with an interest in proposed comparative 
     effectiveness studies by the Center; and
       ``(ii) ensure that any comments from patients regarding 
     proposed comparative effectiveness studies are reviewed by 
     the Center.
       ``(3) Taking into account potential differences.--Research 
     shall--
       ``(A) be designed, as appropriate, to take into account the 
     potential for differences in the effectiveness of health care 
     items, services, and systems used with various subpopulations 
     such as racial and ethnic minorities, women, different age 
     groups (including children, adolescents, adults, and 
     seniors), individuals with disabilities, and individuals with 
     different comorbidities and genetic and molecular subtypes; 
     and--
       ``(B) seek, as feasible and appropriate, to include members 
     of such subpopulations as subjects in the research.
       ``(d) Public Access to Comparative Effectiveness 
     Information.--
       ``(1) In general.--Not later than 90 days after receipt by 
     the Center or Commission, as applicable, of a relevant report 
     described in paragraph (2) made by the Center, Commission, or 
     clinical perspective advisory panel under this section, 
     appropriate information contained in such report shall be 
     posted on the official public Internet site of the Center and 
     of the Commission, as applicable.
       ``(2) Relevant reports described.--For purposes of this 
     section, a relevant report is each of the following submitted 
     by the Center or a grantee or contractor of the Center:
       ``(A) Any interim or progress reports as deemed appropriate 
     by the Secretary.
       ``(B) Stakeholder comments.

[[Page 27298]]

       ``(C) A final report.
       ``(e) Dissemination and Incorporation of Comparative 
     Effectiveness Information.--
       ``(1) Dissemination.--The Center shall provide for the 
     dissemination of appropriate findings produced by research 
     supported, conducted, or synthesized under this section to 
     health care providers, patients, vendors of health 
     information technology focused on clinical decision support, 
     relevant expert organizations (as defined in subsection 
     (i)(3)(A)), and Federal and private health plans, and other 
     relevant stakeholders. In disseminating such findings the 
     Center shall--
       ``(A) convey findings of research so that they are 
     comprehensible and useful to patients and providers in making 
     health care decisions;
       ``(B) discuss findings and other considerations specific to 
     certain sub-populations, risk factors, and comorbidities as 
     appropriate;
       ``(C) include considerations such as limitations of 
     research and what further research may be needed, as 
     appropriate;
       ``(D) not include any data that the dissemination of which 
     would violate the privacy of research participants or violate 
     any confidentiality agreements made with respect to the use 
     of data under this section; and
       ``(E) assist the users of health information technology 
     focused on clinical decision support to promote the timely 
     incorporation of such findings into clinical practices and 
     promote the ease of use of such incorporation.
       ``(2) Dissemination protocols and strategies.--The Center 
     shall develop protocols and strategies for the appropriate 
     dissemination of research findings in order to ensure 
     effective communication of findings and the use and 
     incorporation of such findings into relevant activities for 
     the purpose of informing higher quality and more effective 
     and efficient decisions regarding medical items and services. 
     In developing and adopting such protocols and strategies, the 
     Center shall consult with stakeholders concerning the types 
     of dissemination that will be most useful to the end users of 
     information and may provide for the utilization of multiple 
     formats for conveying findings to different audiences, 
     including dissemination to individuals with limited English 
     proficiency.
       ``(f) Reports to Congress.--
       ``(1) Annual reports.--Beginning not later than one year 
     after the date of the enactment of this section, the Director 
     of the Agency of Healthcare Research and Quality shall submit 
     to Congress an annual report on the activities of the Center, 
     as well as the research, conducted under this section. Each 
     such report shall include a discussion of the Center's 
     compliance with subsection (c)(3)(B), including any reasons 
     for lack of compliance with such subsection.
       ``(2) Recommendation for fair share per capita amount for 
     all-payer financing.--Beginning not later than December 31, 
     2011, the Secretary shall submit to Congress an annual 
     recommendation for a fair share per capita amount described 
     in subsection (c)(1) of section 9511 of the Internal Revenue 
     Code of 1986 for purposes of funding the CERTF under such 
     section.
       ``(3) Analysis and review.--Not later than December 31, 
     2013, the Secretary, in consultation with the Commission, 
     shall submit to Congress a report on all activities conducted 
     or supported under this section as of such date. Such report 
     shall include an evaluation of the overall costs of such 
     activities and an analysis of the backlog of any research 
     proposals approved by the Center but not funded.
       ``(g) Funding of Comparative Effectiveness Research.--For 
     fiscal year 2010 and each subsequent fiscal year, amounts in 
     the Comparative Effectiveness Research Trust Fund (referred 
     to in this section as the `CERTF') under section 9511 of the 
     Internal Revenue Code of 1986 shall be available in 
     accordance with such section, without the need for further 
     appropriations and without fiscal year limitation, to carry 
     out this section.
       ``(h) Construction.--
       ``(1) Coverage.--Nothing in this section shall be 
     construed--
       ``(A) to permit the Center or Commission to mandate 
     coverage, reimbursement, or other policies for any public or 
     private payer; or
       ``(B) as preventing the Secretary from covering the routine 
     costs of clinical care received by an individual entitled to, 
     or enrolled for, benefits under title XVIII, XIX, or XXI in 
     the case where such individual is participating in a clinical 
     trial and such costs would otherwise be covered under such 
     title with respect to the beneficiary.
       ``(2) Reports and findings.--None of the reports submitted 
     under this section or research findings disseminated by the 
     Center or Commission shall be construed as mandates, for 
     payment, coverage, or treatment.
       ``(3) Protecting the physician-patient relationship.--
     Nothing in this section shall be construed to authorize any 
     Federal officer or employee to exercise any supervision or 
     control over the practice of medicine.
       ``(i) Consultation With Relevant Expert Organizations.--
       ``(1) Consultation prior to initiation of research.--Prior 
     to recommending priorities or initiating research described 
     in this section, the Commission or the Center shall consult 
     with the relevant expert organizations responsible for 
     standards and protocols of clinical excellence. Such 
     consultation shall be consistent with the processes 
     established under subsection (c)(2).
       ``(2) Consultation in dissemination of research.--Any 
     dissemination of research from the Commission or the Center 
     and findings made by the Commission or the Center shall be 
     consistent with processes established under subsection (e) 
     and shall--
       ``(A) be based upon evidence-based medicine; and
       ``(B) take into consideration standards and protocols of 
     clinical excellence developed by relevant expert 
     organizations.
       ``(3) Definitions.--For purposes of this subsection:
       ``(A) Relevant expert organizations.--The term `relevant 
     expert organization' means an organization with expertise in 
     the rigorous application of evidence-based scientific methods 
     for the design of clinical studies, the interpretation of 
     clinical data, and the development of national clinical 
     practice guidelines, including a voluntary health 
     organization, clinical specialty, or other professional 
     organization that represents physicians based on the field of 
     medicine in which each such physician practices or is board 
     certified.
       ``(B) Standards and protocols of clinical excellence.--The 
     term `standards and protocols of clinical excellence' means 
     clinical or practice guidelines that consist of a set of 
     directions or principles that is based on evidence and is 
     designed to assist a health care practitioner with decisions 
     about appropriate diagnostic, therapeutic, or other clinical 
     procedures for specific clinical circumstances.
       ``(j) Research May Not Be Used To Deny or Ration Care.--
     Nothing in this section shall be construed to make more 
     stringent or otherwise change the standards or requirements 
     for coverage of items and services under this Act.''.
       (b) Comparative Effectiveness Research Trust Fund; 
     Financing for the Trust Fund.--For the provision establishing 
     a Comparative Effectiveness Research Trust Fund and financing 
     such Trust Fund, see section 1802.

                 Subtitle B--Nursing Home Transparency

   PART 1--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING 
  FACILITIES, NURSING FACILITIES, AND OTHER LONG-TERM CARE FACILITIES

     SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL 
                   DISCLOSABLE PARTIES INFORMATION.

       (a) In General.--Section 1124 of the Social Security Act 
     (42 U.S.C. 1320a-3) is amended by adding at the end the 
     following new subsection:
       ``(c) Required Disclosure of Ownership and Additional 
     Disclosable Parties Information.--
       ``(1) Disclosure.--A facility (as defined in paragraph 
     (6)(B)) shall have the information described in paragraph (3) 
     available--
       ``(A) during the period beginning on the date of the 
     enactment of this subsection and ending on the date such 
     information is made available to the public under section 
     1411(b) of the Affordable Health Care for America Act, for 
     submission to the Secretary, the Inspector General of the 
     Department of Health and Human Services, the State in which 
     the facility is located, and the State long-term care 
     ombudsman in the case where the Secretary, the Inspector 
     General, the State, or the State long-term care ombudsman 
     requests such information; and
       ``(B) beginning on the effective date of the final 
     regulations promulgated under paragraph (4)(A), for reporting 
     such information in accordance with such final regulations.
     Nothing in subparagraph (A) shall be construed as authorizing 
     a facility to dispose of or delete information described in 
     such subparagraph after the effective date of the final 
     regulations promulgated under paragraph (4)(A).
       ``(2) Public availability of information.--During the 
     period described in paragraph (1)(A), a facility shall--
       ``(A) make the information described in paragraph (3) 
     available to the public upon request and update such 
     information as may be necessary to reflect changes in such 
     information; and
       ``(B) post a notice of the availability of such information 
     in the lobby of the facility in a prominent manner.
       ``(3) Information described.--
       ``(A) In general.--The following information is described 
     in this paragraph:
       ``(i) The information described in subsections (a) and (b), 
     subject to subparagraph (C).
       ``(ii) The identity of and information on--

       ``(I) each member of the governing body of the facility, 
     including the name, title, and period of service of each such 
     member;
       ``(II) each person or entity who is an officer, director, 
     member, partner, trustee, or managing employee of the 
     facility, including the name, title, and date of start of 
     service of each such person or entity; and
       ``(III) each person or entity who is an additional 
     disclosable party of the facility.

       ``(iii) A description of the organizational structure and 
     the relationship of each person and entity described in 
     subclauses (II) and (III) of clause (ii) to the facility and 
     to one another.

[[Page 27299]]

       ``(B) Special rule where information is already reported or 
     submitted.--To the extent that information reported by a 
     facility to the Internal Revenue Service on Form 990, 
     information submitted by a facility to the Securities and 
     Exchange Commission, or information otherwise submitted to 
     the Secretary or any other Federal agency contains the 
     information described in clauses (i), (ii), or (iii) of 
     subparagraph (A), the Secretary may allow, to the extent 
     practicable, such Form or such information to meet the 
     requirements of paragraph (1) and to be submitted in a manner 
     specified by the Secretary.
       ``(C) Special rule.--In applying subparagraph (A)(i)--
       ``(i) with respect to subsections (a) and (b), `ownership 
     or control interest' shall include direct or indirect 
     interests, including such interests in intermediate entities; 
     and
       ``(ii) subsection (a)(3)(A)(ii) shall include the owner of 
     a whole or part interest in any mortgage, deed of trust, 
     note, or other obligation secured, in whole or in part, by 
     the entity or any of the property or assets thereof, if the 
     interest is equal to or exceeds 5 percent of the total 
     property or assets of the entirety.
       ``(4) Reporting.--
       ``(A) In general.--Not later than the date that is 2 years 
     after the date of the enactment of this subsection, the 
     Secretary shall promulgate regulations requiring a facility 
     to report the information described in paragraph (3) to the 
     Secretary in a standardized format, and such other 
     regulations as are necessary to carry out this subsection. 
     Such regulations shall specify the frequency of reporting, as 
     determined by the Secretary. Such final regulations shall 
     also require--
       ``(i) the reporting of such information on or after the 
     first day of the first calendar quarter beginning after the 
     date that is 90 days after the date on which such final 
     regulations are published in the Federal Register; and--
       ``(ii) the certification, as a condition of participation 
     under the program under title XVIII or XIX, that such 
     information is accurate and current.
       ``(B) Guidance.--The Secretary shall provide guidance and 
     technical assistance to States on how to adopt the 
     standardized format under subparagraph (A).
       ``(5) No effect on existing reporting requirements.--
     Nothing in this subsection shall reduce, diminish, or alter 
     any reporting requirement for a facility that is in effect as 
     of the date of the enactment of this subsection.
       ``(6) Definitions.--In this subsection:
       ``(A) Additional disclosable party.--The term `additional 
     disclosable party' means, with respect to a facility, any 
     person or entity who, through ownership interest, partnership 
     interest, contract, or otherwise--
       ``(i) directly or indirectly exercises operational, 
     financial, administrative, or managerial control or direction 
     over the facility or a part thereof, or provides policies or 
     procedures for any of the operations of the facility, or 
     provides financial or cash management services to the 
     facility;
       ``(ii) leases or subleases real property to the facility, 
     or owns a whole or part interest equal to or exceeding 5 
     percent of the total value of such real property;
       ``(iii) lends funds or provides a financial guarantee to 
     the facility in an amount which is equal to or exceeds 
     $50,000; or
       ``(iv) provides management or administrative services, 
     clinical consulting services, or accounting or financial 
     services to the facility.
       ``(B) Facility.--The term `facility' means a disclosing 
     entity which is--
       ``(i) a skilled nursing facility (as defined in section 
     1819(a)); or
       ``(ii) a nursing facility (as defined in section 1919(a)).
       ``(C) Managing employee.--The term `managing employee' 
     means, with respect to a facility, an individual (including a 
     general manager, business manager, administrator, director, 
     or consultant) who directly or indirectly manages, advises, 
     or supervises any element of the practices, finances, or 
     operations of the facility.
       ``(D) Organizational structure.--The term `organizational 
     structure' means, in the case of--
       ``(i) a corporation, the officers, directors, and 
     shareholders of the corporation who have an ownership 
     interest in the corporation which is equal to or exceeds 5 
     percent;
       ``(ii) a limited liability company, the members and 
     managers of the limited liability company (including, as 
     applicable, what percentage each member and manager has of 
     the ownership interest in the limited liability company);
       ``(iii) a general partnership, the partners of the general 
     partnership;
       ``(iv) a limited partnership, the general partners and any 
     limited partners of the limited partnership who have an 
     ownership interest in the limited partnership which is equal 
     to or exceeds 10 percent;
       ``(v) a trust, the trustees of the trust;
       ``(vi) an individual, contact information for the 
     individual; and
       ``(vii) any other person or entity, such information as the 
     Secretary determines appropriate.''.
       (b) Public Availability of Information.--Not later than the 
     date that is 1 year after the date on which the final 
     regulations promulgated under section 1124(c)(4)(A) of the 
     Social Security Act, as added by subsection (a), are 
     published in the Federal Register, the information reported 
     in accordance with such final regulations shall be made 
     available to the public in accordance with procedures 
     established by the Secretary of Health and Human Services.
       (c) Conforming Amendments.--
       (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
     Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by 
     striking subparagraph (B) and redesignating subparagraph (C) 
     as subparagraph (B).
       (2) Nursing facilities.--Section 1919(d)(1) of the Social 
     Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking 
     subparagraph (B) and redesignating subparagraph (C) as 
     subparagraph (B).

     SEC. 1412. ACCOUNTABILITY REQUIREMENTS.

       (a) Effective Compliance and Ethics Programs.--
       (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
     Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
     section 1411(c)(1), is amended by adding at the end the 
     following new subparagraph:
       ``(C) Compliance and ethics programs.--
       ``(i) Requirement.--On or after the first day of the first 
     calendar quarter beginning after the date that is 1 year 
     after the date on which regulations developed under clause 
     (ii) are published in the Federal Register, a skilled nursing 
     facility shall, with respect to the entity that operates or 
     controls the facility (in this subparagraph referred to as 
     the `operating organization' or `organization'), have in 
     operation a compliance and ethics program that is effective 
     in preventing and detecting criminal, civil, and 
     administrative violations under this Act and in promoting 
     quality of care consistent with such regulations.
       ``(ii) Development of regulations.--

       ``(I) In general.--Not later than the date that is 2 years 
     after the date of the enactment of this subparagraph, the 
     Secretary, in consultation with the Inspector General of the 
     Department of Health and Human Services, shall promulgate 
     regulations for an effective compliance and ethics program 
     for operating organizations, which may include a model 
     compliance program.
       ``(II) Design of regulations.--Such regulations with 
     respect to specific elements or formality of a program may 
     vary with the size of the organization, such that larger 
     organizations should have a more formal and rigorous program 
     and include established written policies defining the 
     standards and procedures to be followed by its employees. 
     Such requirements shall specifically apply to the corporate 
     level management of multi-unit nursing home chains.
       ``(III) Evaluation.--Not later than 3 years after the date 
     on which compliance and ethics programs established under 
     this subparagraph are in operation pursuant to clause (i), 
     the Secretary shall complete an evaluation of such programs. 
     Such evaluation shall determine if such programs led to 
     changes in deficiency citations, changes in quality 
     performance, or changes in other metrics of resident quality 
     of care. The Secretary shall submit to Congress a report on 
     such evaluation and shall include in such report such 
     recommendations regarding changes in the requirements for 
     such programs as the Secretary determines appropriate.

       ``(iii) Requirements for compliance and ethics programs.--
     In this subparagraph, the term `compliance and ethics 
     program' means, with respect to a skilled nursing facility, a 
     program of the operating organization that--

       ``(I) has been reasonably designed, implemented, and 
     enforced so that it generally will be effective in preventing 
     and detecting criminal, civil, and administrative violations 
     under this Act and in promoting quality of care; and
       ``(II) includes at least the required components specified 
     in clause (iv).

       ``(iv) Required components of program.--The required 
     components of a compliance and ethics program of an 
     organization are the following:

       ``(I) The organization must have established compliance 
     standards and procedures to be followed by its employees, 
     contractors, and other agents that are reasonably capable of 
     reducing the prospect of criminal, civil, and administrative 
     violations under this Act.
       ``(II) Specific individuals within high-level personnel of 
     the organization must have been assigned overall 
     responsibility to oversee compliance with such standards and 
     procedures and have sufficient resources and authority to 
     assure such compliance.
       ``(III) The organization must have used due care not to 
     delegate substantial discretionary authority to individuals 
     whom the organization knew, or should have known through the 
     exercise of due diligence, had a propensity to engage in 
     criminal, civil, and administrative violations under this 
     Act.
       ``(IV) The organization must have taken steps to 
     communicate effectively its standards and procedures to all 
     employees and other agents, such as by requiring 
     participation in training programs or by disseminating 
     publications that explain in a practical manner what is 
     required.
       ``(V) The organization must have taken reasonable steps to 
     achieve compliance with

[[Page 27300]]

     its standards, such as by utilizing monitoring and auditing 
     systems reasonably designed to detect criminal, civil, and 
     administrative violations under this Act by its employees and 
     other agents and by having in place and publicizing a 
     reporting system whereby employees and other agents could 
     report violations by others within the organization without 
     fear of retribution.
       ``(VI) The standards must have been consistently enforced 
     through appropriate disciplinary mechanisms, including, as 
     appropriate, discipline of individuals responsible for the 
     failure to detect an offense.
       ``(VII) After an offense has been detected, the 
     organization must have taken all reasonable steps to respond 
     appropriately to the offense and to prevent further similar 
     offenses, including repayment of any funds to which it was 
     not entitled and any necessary modification to its program to 
     prevent and detect criminal, civil, and administrative 
     violations under this Act.
       ``(VIII) The organization must periodically undertake 
     reassessment of its compliance program to identify changes 
     necessary to reflect changes within the organization and its 
     facilities.

       ``(v) Coordination.--The provisions of this subparagraph 
     shall apply with respect to a skilled nursing facility in 
     lieu of section 1874(d).''.
       (2) Nursing facilities.--Section 1919(d)(1) of the Social 
     Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 
     1411(c)(2), is amended by adding at the end the following new 
     subparagraph:
       ``(C) Compliance and ethics program.--
       ``(i) Requirement.--On or after the first day of the first 
     calendar quarter beginning after the date that is 1 year 
     after the date on which regulations developed under clause 
     (ii) are published in the Federal Register, a skilled nursing 
     facility shall, with respect to the entity that operates or 
     controls the facility (in this subparagraph referred to as 
     the `operating organization' or `organization'), have in 
     operation a compliance and ethics program that is effective 
     in preventing and detecting criminal, civil, and 
     administrative violations under this Act and in promoting 
     quality of care consistent with such regulations.
       ``(iii) Development of regulations.--

       ``(I) In general.--Not later than the date that is 2 years 
     after the date of the enactment of this subparagraph, the 
     Secretary, in consultation with the Inspector General of the 
     Department of Health and Human Services, shall promulgate 
     regulations for an effective compliance and ethics program 
     for operating organizations, which may include a model 
     compliance program.
       ``(II) Design of regulations.--Such regulations with 
     respect to specific elements or formality of a program may 
     vary with the size of the organization, such that larger 
     organizations should have a more formal and rigorous program 
     and include established written policies defining the 
     standards and procedures to be followed by its employees. 
     Such requirements shall specifically apply to the corporate 
     level management of multi-unit nursing home chains.
       ``(III) Evaluation.--Not later than 3 years after the date 
     on which compliance and ethics programs established under 
     this subparagraph are in operation pursuant to clause (i), 
     the Secretary shall complete an evaluation of such programs. 
     Such evaluation shall determine if such programs led to 
     changes in deficiency citations, changes in quality 
     performance, or changes in other metrics of resident quality 
     of care. The Secretary shall submit to Congress a report on 
     such evaluation and shall include in such report such 
     recommendations regarding changes in the requirements for 
     such programs as the Secretary determines appropriate.

       ``(v) Requirements for compliance and ethics programs.--In 
     this subparagraph, the term `compliance and ethics program' 
     means, with respect to a nursing facility, a program of the 
     operating organization that--

       ``(I) has been reasonably designed, implemented, and 
     enforced so that it generally will be effective in preventing 
     and detecting criminal, civil, and administrative violations 
     under this Act and in promoting quality of care; and
       ``(II) includes at least the required components specified 
     in clause (iv).

       ``(vi) Required components of program.--The required 
     components of a compliance and ethics program of an 
     organization are the following:

       ``(I) The organization must have established compliance 
     standards and procedures to be followed by its employees and 
     other agents that are reasonably capable of reducing the 
     prospect of criminal, civil, and administrative violations 
     under this Act.
       ``(II) Specific individuals within high-level personnel of 
     the organization must have been assigned overall 
     responsibility to oversee compliance with such standards and 
     procedures and has sufficient resources and authority to 
     assure such compliance.
       ``(III) The organization must have used due care not to 
     delegate substantial discretionary authority to individuals 
     whom the organization knew, or should have known through the 
     exercise of due diligence, had a propensity to engage in 
     criminal, civil, and administrative violations under this 
     Act.
       ``(IV) The organization must have taken steps to 
     communicate effectively its standards and procedures to all 
     employees and other agents, such as by requiring 
     participation in training programs or by disseminating 
     publications that explain in a practical manner what is 
     required.
       ``(V) The organization must have taken reasonable steps to 
     achieve compliance with its standards, such as by utilizing 
     monitoring and auditing systems reasonably designed to detect 
     criminal, civil, and administrative violations under this Act 
     by its employees and other agents and by having in place and 
     publicizing a reporting system whereby employees and other 
     agents could report violations by others within the 
     organization without fear of retribution.
       ``(VI) The standards must have been consistently enforced 
     through appropriate disciplinary mechanisms, including, as 
     appropriate, discipline of individuals responsible for the 
     failure to detect an offense.
       ``(VII) After an offense has been detected, the 
     organization must have taken all reasonable steps to respond 
     appropriately to the offense and to prevent further similar 
     offenses, including repayment of any funds to which it was 
     not entitled and any necessary modification to its program to 
     prevent and detect criminal, civil, and administrative 
     violations under this Act.
       ``(VIII) The organization must periodically undertake 
     reassessment of its compliance program to identify changes 
     necessary to reflect changes within the organization and its 
     facilities.

       ``(vii) Coordination.--The provisions of this subparagraph 
     shall apply with respect to a nursing facility in lieu of 
     section 1902(a)(77).''.
       (b) Quality Assurance and Performance Improvement 
     Program.--
       (1) Skilled nursing facilities.--Section 1819(b)(1)(B) of 
     the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is 
     amended--
       (A) by striking ``assurance'' and inserting ``assurance and 
     quality assurance and performance improvement program'';
       (B) by designating the matter beginning with ``A skilled 
     nursing facility'' as a clause (i) with the heading ``In 
     general.--'' and the appropriate indentation;
       (C) in clause (i) (as so designated by subparagraph (B)), 
     by redesignating clauses (i) and (ii) as subclauses (I) and 
     (II), respectively; and
       (D) by adding at the end the following new clause:
       ``(ii) Quality assurance and performance improvement 
     program.--

       ``(I) In general.--Not later than December 31, 2011, the 
     Secretary shall establish and implement a quality assurance 
     and performance improvement program (in this clause referred 
     to as the `QAPI program') for skilled nursing facilities, 
     including multi-unit chains of such facilities. Under the 
     QAPI program, the Secretary shall establish standards 
     relating to such facilities and provide technical assistance 
     to such facilities on the development of best practices in 
     order to meet such standards. Not later than 1 year after the 
     date on which the regulations are promulgated under subclause 
     (II), a skilled nursing facility must submit to the Secretary 
     a plan for the facility to meet such standards and implement 
     such best practices, including how to coordinate the 
     implementation of such plan with quality assessment and 
     assurance activities conducted under clause (i).
       ``(II) Regulations.--The Secretary shall promulgate 
     regulations to carry out this clause.''.

       (2) Nursing facilities.--Section 1919(b)(1)(B) of the 
     Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
       (A) by striking ``assurance'' and inserting ``assurance and 
     quality assurance and performance improvement program'';
       (B) by designating the matter beginning with ``A nursing 
     facility'' as a clause (i) with the heading ``In general.--'' 
     and the appropriate indentation; and
       (C) by adding at the end the following new clause:
       ``(ii) Quality assurance and performance improvement 
     program.--

       ``(I) In general.--Not later than December 31, 2011, the 
     Secretary shall establish and implement a quality assurance 
     and performance improvement program (in this clause referred 
     to as the `QAPI program') for nursing facilities, including 
     multi-unit chains of such facilities. Under the QAPI program, 
     the Secretary shall establish standards relating to such 
     facilities and provide technical assistance to such 
     facilities on the development of best practices in order to 
     meet such standards. Not later than 1 year after the date on 
     which the regulations are promulgated under subclause (II), a 
     nursing facility must submit to the Secretary a plan for the 
     facility to meet such standards and implement such best 
     practices, including how to coordinate the implementation of 
     such plan with quality assessment and assurance activities 
     conducted under clause (i).
       ``(II) Regulations.--The Secretary shall promulgate 
     regulations to carry out this clause.''.

       (3) Proposal to revise quality assurance and performance 
     improvement programs.--The Secretary shall implement policies 
     that modify and strengthen quality assurance and performance 
     improvement programs in

[[Page 27301]]

     skilled nursing facilities and nursing facilities on a 
     periodic basis, as determined by the Secretary.
       (4) Facility plan.--Not later than 1 year after the date on 
     which the regulations are promulgated under subclause (II) of 
     clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of 
     the Social Security Act, as added by paragraphs (1) and (2), 
     a skilled nursing facility and a nursing facility must submit 
     to the Secretary a plan for the facility to meet the 
     standards under such regulations and implement such best 
     practices, including how to coordinate the implementation of 
     such plan with quality assessment and assurance activities 
     conducted under clause (i) of such sections.
       (c) GAO Study on Nursing Facility Undercapitalization.--
       (1) In general.--The Comptroller General of the United 
     States shall conduct a study that examines the following:
       (A) The extent to which corporations that own or operate 
     large numbers of nursing facilities, taking into account 
     ownership type (including private equity and control 
     interests), are undercapitalizing such facilities.
       (B) The effects of such undercapitalization on quality of 
     care, including staffing and food costs, at such facilities.
       (C) Options to address such undercapitalization, such as 
     requirements relating to surety bonds, liability insurance, 
     or minimum capitalization.
       (2) Report.--Not later than 18 months after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report on the study conducted under paragraph 
     (1).
       (3) Nursing facility.--In this subsection, the term 
     ``nursing facility'' includes a skilled nursing facility.

     SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819 of the Social Security Act 
     (42 U.S.C. 1395i-3) is amended--
       (A) by redesignating subsection (i) as subsection (j); and
       (B) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Nursing Home Compare Website.--
       ``(1) Inclusion of additional information.--
       ``(A) In general.--The Secretary shall ensure that the 
     Department of Health and Human Services includes, as part of 
     the information provided for comparison of nursing homes on 
     the official Internet website of the Federal Government for 
     Medicare beneficiaries (commonly referred to as the `Nursing 
     Home Compare' Medicare website) (or a successor website), the 
     following information in a manner that is prominent, easily 
     accessible, readily understandable to consumers of long-term 
     care services, and searchable:
       ``(i) Information that is reported to the Secretary under 
     section 1124(c)(4).
       ``(ii) Information on the `Special Focus Facility program' 
     (or a successor program) established by the Centers for 
     Medicare and Medicaid Services, according to procedures 
     established by the Secretary. Such procedures shall provide 
     for the inclusion of information with respect to, and the 
     names and locations of, those facilities that, since the 
     previous quarter--

       ``(I) were newly enrolled in the program;
       ``(II) are enrolled in the program and have failed to 
     significantly improve;
       ``(III) are enrolled in the program and have significantly 
     improved;
       ``(IV) have graduated from the program; and
       ``(V) have closed voluntarily or no longer participate 
     under this title.

       ``(iii) Staffing data for each facility (including resident 
     census data and data on the hours of care provided per 
     resident per day) based on data submitted under subsection 
     (b)(8)(C), including information on staffing turnover and 
     tenure, in a format that is clearly understandable to 
     consumers of long-term care services and allows such 
     consumers to compare differences in staffing between 
     facilities and State and national averages for the 
     facilities. Such format shall include--

       ``(I) concise explanations of how to interpret the data 
     (such as a plain English explanation of data reflecting 
     `nursing home staff hours per resident day');
       ``(II) differences in types of staff (such as training 
     associated with different categories of staff);
       ``(III) the relationship between nurse staffing levels and 
     quality of care; and
       ``(IV) an explanation that appropriate staffing levels vary 
     based on patient case mix.

       ``(iv) Links to State internet websites with information 
     regarding State survey and certification programs, links to 
     Form 2567 State inspection reports (or a successor form) on 
     such websites, information to guide consumers in how to 
     interpret and understand such reports, and the facility plan 
     of correction or other response to such report.
       ``(v) The standardized complaint form developed under 
     subsection (f)(8), including explanatory material on what 
     complaint forms are, how they are used, and how to file a 
     complaint with the State survey and certification program and 
     the State long-term care ombudsman program.
       ``(vi) Summary information on the number, type, severity, 
     and outcome of substantiated complaints.
       ``(vii) The number of adjudicated instances of criminal 
     violations by employees of a nursing facility--

       ``(I) that were committed inside the facility;
       ``(II) with respect to such instances of violations or 
     crimes committed inside of the facility that were the 
     violations or crimes of abuse, neglect, and exploitation, 
     criminal sexual abuse, or other violations or crimes that 
     resulted in serious bodily injury; and

       ``(viii) The number of civil monetary penalties levied 
     against the facility, employees, contractors, and other 
     agents.
       ``(ix) Any other information that the Secretary determines 
     appropriate.

     The facility shall not make available under clause (iv) 
     identifying information on complainants or residents.
       ``(B) Deadline for provision of information.--
       ``(i) In general.--Except as provided in clause (ii), the 
     Secretary shall ensure that the information described in 
     subparagraph (A) is included on such website (or a successor 
     website) not later than 1 year after the date of the 
     enactment of this subsection.
       ``(ii) Exception.--The Secretary shall ensure that the 
     information described in subparagraph (A)(i) and (A)(iii) is 
     included on such website (or a successor website) not later 
     than 1 year after the dates on which the data are submitted 
     to the Secretary pursuant to section 1124(c)(4) and 
     subsection (b)(8)(C), respectively.
       ``(2) Review and modification of website.--
       ``(A) In general.--The Secretary shall establish a 
     process--
       ``(i) to review the accuracy, clarity of presentation, 
     timeliness, and comprehensiveness of information reported on 
     such website as of the day before the date of the enactment 
     of this subsection; and
       ``(ii) not later than 1 year after the date of the 
     enactment of this subsection, to modify or revamp such 
     website in accordance with the review conducted under clause 
     (i).
       ``(B) Consultation.--In conducting the review under 
     subparagraph (A)(i), the Secretary shall consult with--
       ``(i) State long-term care ombudsman programs;
       ``(ii) consumer advocacy groups;
       ``(iii) provider stakeholder groups; and
       ``(iv) any other representatives of programs or groups the 
     Secretary determines appropriate.''.
       (2) Timeliness of submission of survey and certification 
     information.--
       (A) In general.--Section 1819(g)(5) of the Social Security 
     Act (42 U.S.C. 1395i-3(g)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(E) Submission of survey and certification information to 
     the secretary.--In order to improve the timeliness of 
     information made available to the public under subparagraph 
     (A) and provided on the Nursing Home Compare Medicare website 
     under subsection (i), each State shall submit information 
     respecting any survey or certification recommendation made 
     respecting a skilled nursing facility (including any 
     enforcement actions taken by the State or any Federal 
     enforcement action recommended by the State) to the Secretary 
     not later than the date on which the State sends such 
     information to the facility. The Secretary shall use the 
     information submitted under the preceding sentence to update 
     the information provided on the Nursing Home Compare Medicare 
     website as expeditiously as practicable but not less 
     frequently than quarterly.''.
       (B) Effective date.--The amendment made by this paragraph 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (3) Special focus facility program.--Section 1819(f) of 
     such Act is amended by adding at the end the following new 
     paragraph:
       ``(8) Special focus facility program.--
       ``(A) In general.--The Secretary shall conduct a special 
     focus facility program for enforcement of requirements for 
     skilled nursing facilities that the Secretary has identified 
     as having a poor compliance history or that substantially 
     failed to meet applicable requirements of this Act.
       ``(B) Periodic surveys.--Under such program the Secretary 
     shall conduct surveys of each facility in the program not 
     less than once every 6 months.''.
       (b) Nursing Facilities.--
       (1) In general.--Section 1919 of the Social Security Act 
     (42 U.S.C. 1396r) is amended--
       (A) by redesignating subsection (i) as subsection (j); and
       (B) by inserting after subsection (h) the following new 
     subsection:
       ``(i) Nursing Home Compare Website.--
       ``(1) Inclusion of additional information.--
       ``(A) In general.--The Secretary shall ensure that the 
     Department of Health and Human Services includes, as part of 
     the information provided for comparison of nursing homes on 
     the official internet website of the Federal Government for 
     Medicare beneficiaries (commonly referred to as the `Nursing 
     Home Compare' Medicare website) (or a successor website), the 
     following information in a manner that is prominent, easily

[[Page 27302]]

     accessible, readily understandable to consumers of long-term 
     care services, and searchable:
       ``(i) Information that is reported to the Secretary under 
     section 1124(c)(4)
       ``(ii) Information on the `Special Focus Facility program' 
     (or a successor program) established by the Centers for 
     Medicare & Medicaid Services, according to procedures 
     established by the Secretary. Such procedures shall provide 
     for the inclusion of information with respect to, and the 
     names and locations of, those facilities that, since the 
     previous quarter--

       ``(I) were newly enrolled in the program;
       ``(II) are enrolled in the program and have failed to 
     significantly improve;
       ``(III) are enrolled in the program and have significantly 
     improved;
       ``(IV) have graduated from the program; and
       ``(V) have closed voluntarily or no longer participate 
     under this title.

       ``(iii) Staffing data for each facility (including resident 
     census data and data on the hours of care provided per 
     resident per day) based on data submitted under subsection 
     (b)(8)(C)(ii), including information on staffing turnover and 
     tenure, in a format that is clearly understandable to 
     consumers of long-term care services and allows such 
     consumers to compare differences in staffing between 
     facilities and State and national averages for the 
     facilities. Such format shall include--

       ``(I) concise explanations of how to interpret the data 
     (such as plain English explanation of data reflecting 
     `nursing home staff hours per resident day');
       ``(II) differences in types of staff (such as training 
     associated with different categories of staff);
       ``(III) the relationship between nurse staffing levels and 
     quality of care; and
       ``(IV) an explanation that appropriate staffing levels vary 
     based on patient case mix.

       ``(iv) Links to State internet websites with information 
     regarding State survey and certification programs, links to 
     Form 2567 State inspection reports (or a successor form) on 
     such websites, information to guide consumers in how to 
     interpret and understand such reports, and the facility plan 
     of correction or other response to such report.
       ``(v) The standardized complaint form developed under 
     subsection (f)(10), including explanatory material on what 
     complaint forms are, how they are used, and how to file a 
     complaint with the State survey and certification program and 
     the State long-term care ombudsman program.
       ``(vi) Summary information on the number, type, severity, 
     and outcome of substantiated complaints.
       ``(vii) The number of adjudicated instances of criminal 
     violations by employees of a nursing facility--

       ``(I) that were committed inside of the facility; and
       ``(II) with respect to such instances of violations or 
     crimes committed inside of the facility that were the 
     violations or crimes of abuse, neglect, and exploitation, 
     criminal sexual abuse, or other violations or crimes that 
     resulted in serious bodily injury.

       ``(viii) the number of civil monetary penalties levied 
     against the facility, employees, contractors, and other 
     agents.
       ``(ix) Any other information that the Secretary determines 
     appropriate.

     The facility shall not make available under clause (ii) 
     identifying information about complainants or residents.
       ``(B) Deadline for provision of information.--
       ``(i) In general.--Except as provided in clause (ii), the 
     Secretary shall ensure that the information described in 
     subparagraph (A) is included on such website (or a successor 
     website) not later than 1 year after the date of the 
     enactment of this subsection.
       ``(ii) Exception.--The Secretary shall ensure that the 
     information described in subparagraph (A)(i) and (A)(iii) is 
     included on such website (or a successor website) not later 
     than 1 year after the dates on which the data are submitted 
     to the Secretary pursuant to section 1124(c)(4) and 
     subsection (b)(8)(C), respectively.
       ``(2) Review and modification of website.--
       ``(A) In general.--The Secretary shall establish a 
     process--
       ``(i) to review the accuracy, clarity of presentation, 
     timeliness, and comprehensiveness of information reported on 
     such website as of the day before the date of the enactment 
     of this subsection; and
       ``(ii) not later than 1 year after the date of the 
     enactment of this subsection, to modify or revamp such 
     website in accordance with the review conducted under clause 
     (i).
       ``(B) Consultation.--In conducting the review under 
     subparagraph (A)(i), the Secretary shall consult with--
       ``(i) State long-term care ombudsman programs;
       ``(ii) consumer advocacy groups;
       ``(iii) provider stakeholder groups;
       ``(iv) skilled nursing facility employees and their 
     representatives; and
       ``(v) any other representatives of programs or groups the 
     Secretary determines appropriate.''.
       (2) Timeliness of submission of survey and certification 
     information.--
       (A) In general.--Section 1919(g)(5) of the Social Security 
     Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end 
     the following new subparagraph:
       ``(E) Submission of survey and certification information to 
     the secretary.--In order to improve the timeliness of 
     information made available to the public under subparagraph 
     (A) and provided on the Nursing Home Compare Medicare website 
     under subsection (i), each State shall submit information 
     respecting any survey or certification recommendation made 
     respecting a nursing facility (including any enforcement 
     actions taken by the State or any Federal enforcement action 
     recommended by the State) to the Secretary not later than the 
     date on which the State sends such information to the 
     facility. The Secretary shall use the information submitted 
     under the preceding sentence to update the information 
     provided on the Nursing Home Compare Medicare website as 
     expeditiously as practicable but not less frequently than 
     quarterly.''.
       (B) Effective date.--The amendment made by this paragraph 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (3) Special focus facility program.--Section 1919(f) of 
     such Act is amended by adding at the end of the following new 
     paragraph:
       ``(10) Special focus facility program.--
       ``(A) In general.--The Secretary shall conduct a special 
     focus facility program for enforcement of requirements for 
     nursing facilities that the Secretary has identified as 
     having a poor compliance history or that substantially failed 
     to meet applicable requirements of this Act.
       ``(B) Periodic surveys.--Under such program the Secretary 
     shall conduct surveys of each facility in the program not 
     less often than once every 6 months.''.
       (c) Availability of Reports on Surveys, Certifications, and 
     Complaint Investigations.--
       (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
     Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
     sections 1411 and 1412, is amended by adding at the end the 
     following new subparagraph:
       ``(D) Availability of survey, certification, and complaint 
     investigation reports.--A skilled nursing facility must--
       ``(i) have reports with respect to any surveys, 
     certifications, and complaint investigations made respecting 
     the facility during the 3 preceding years available for any 
     individual to review upon request; and
       ``(ii) post notice of the availability of such reports in 
     areas of the facility that are prominent and accessible to 
     the public.
     The facility shall not make available under clause (i) 
     identifying information about complainants or residents.''.
       (2) Nursing facilities.--Section 1919(d)(1) of the Social 
     Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections 
     1411 and 1412, is amended by adding at the end the following 
     new subparagraph:
       ``(D) Availability of survey, certification, and complaint 
     investigation reports.--A nursing facility must--
       ``(i) have reports with respect to any surveys, 
     certifications, and complaint investigations made respecting 
     the facility during the 3 preceding years available for any 
     individual to review upon request; and
       ``(ii) post notice of the availability of such reports in 
     areas of the facility that are prominent and accessible to 
     the public.

     The facility shall not make available under clause (i) 
     identifying information about complainants or residents.''.
       (3) Effective date.--The amendments made by this subsection 
     shall take effect 1 year after the date of the enactment of 
     this Act.
       (d) Guidance to States on Form 2567 State Inspection 
     Reports and Complaint Investigation Reports.--
       (1) Guidance.--The Secretary of Health and Human Services 
     (in this subtitle referred to as the ``Secretary'') shall 
     provide guidance to States on how States can establish 
     electronic links to Form 2567 State inspection reports (or a 
     successor form), complaint investigation reports, and a 
     facility's plan of correction or other response to such Form 
     2567 State inspection reports (or a successor form) on the 
     Internet website of the State that provides information on 
     skilled nursing facilities and nursing facilities and the 
     Secretary shall, if possible, include such information on 
     Nursing Home Compare.
       (2) Requirement.--Section 1902(a)(9) of the Social Security 
     Act (42 U.S.C. 1396a(a)(9)) is amended--
       (A) by striking ``and'' at the end of subparagraph (B);
       (B) by striking the semicolon at the end of subparagraph 
     (C) and inserting ``, and''; and
       (C) by adding at the end the following new subparagraph:
       ``(D) that the State maintain a consumer-oriented website 
     providing useful information to consumers regarding all 
     skilled nursing facilities and all nursing facilities in the 
     State, including for each facility, Form 2567 State 
     inspection reports (or a successor form), complaint 
     investigation reports, the facility's plan of correction, and 
     such other information that the State or the Secretary 
     considers useful in assisting the public to assess the 
     quality of long term care options

[[Page 27303]]

     and the quality of care provided by individual facilities;''.
       (3) Definitions.--In this subsection:
       (A) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (B) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (C) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395i-3(a)).

     SEC. 1414. REPORTING OF EXPENDITURES.

       Section 1888 of the Social Security Act (42 U.S.C. 1395yy) 
     is amended by adding at the end the following new subsection:
       ``(f) Reporting of Direct Care Expenditures.--
       ``(1) In general.--For cost reports submitted under this 
     title for cost reporting periods beginning on or after the 
     date that is no more than two years after the redesign of the 
     report specified in subparagraph (2), skilled nursing 
     facilities shall--
       ``(A) separately report expenditures for wages and benefits 
     for direct care staff (breaking out (at a minimum) registered 
     nurses, licensed professional nurses, certified nurse 
     assistants, and other medical and therapy staff); and
       ``(B) take into account agency and contract staff in a 
     manner to be determined by the Administrator.
       ``(2) Modification of form.--The Secretary, in consultation 
     with private sector accountants experienced with skilled 
     nursing facility cost reports, shall redesign such reports to 
     meet the requirement of paragraph (1) not later than 2 years 
     after the date of the enactment of this subsection.
       ``(3) Categorization by functional accounts.--Beginning 
     with cost reports submitted under paragraph (1) , the 
     Secretary, working in consultation with the Medicare Payment 
     Advisory Commission, the Inspector General of the Department 
     of Health and Human Services, and other expert parties the 
     Secretary determines appropriate, shall categorize the 
     expenditures listed on cost reports, as modified under 
     paragraph (1), submitted by skilled nursing facilities, 
     regardless of any source of payment for such expenditures, 
     for each skilled nursing facility into the following 
     functional accounts on an annual basis:
       ``(A) Spending on direct care services (including nursing, 
     therapy, and medical services).
       ``(B) Spending on indirect care (including housekeeping and 
     dietary services).
       ``(C) Capital assets (including building and land costs).
       ``(D) Administrative services costs.
       ``(4) Availability of information submitted.--The Secretary 
     shall establish procedures to make information on 
     expenditures submitted under this subsection readily 
     available to interested parties upon request, subject to such 
     requirements as the Secretary may specify under the 
     procedures established under this paragraph.''.

     SEC. 1415. STANDARDIZED COMPLAINT FORM.

       (a) Skilled Nursing Facilities.--
       (1) Development by the secretary.--Section 1819(f) of the 
     Social Security Act (42 U.S.C. 1395i-3(f)), as amended by 
     section 1413(a)(3), is amended by adding at the end the 
     following new paragraph:
       ``(9) Standardized complaint form.--The Secretary shall 
     develop a standardized complaint form for use by a resident 
     (or a person acting on the resident's behalf) in filing a 
     complaint with a State survey and certification agency and a 
     State long-term care ombudsman program with respect to a 
     skilled nursing facility.''.
       (2) State requirements.--Section 1819(e) of the Social 
     Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at 
     the end the following new paragraph:
       ``(6) Complaint processes and whistle-blower protection.--
       ``(A) Complaint forms.--The State must make the 
     standardized complaint form developed under subsection (f)(9) 
     available upon request to--
       ``(i) a resident of a skilled nursing facility;
       ``(ii) any person acting on the resident's behalf; and
       ``(iii) any person who works at a skilled nursing facility 
     or is a representative of such a worker.
       ``(B) Complaint resolution process.--The State must 
     establish a complaint resolution process in order to ensure 
     that a resident, the legal representative of a resident of a 
     skilled nursing facility, or other responsible party is not 
     retaliated against if the resident, legal representative, or 
     responsible party has complained, in good faith, about the 
     quality of care or other issues relating to the skilled 
     nursing facility, that the legal representative of a resident 
     of a skilled nursing facility or other responsible party is 
     not denied access to such resident or otherwise retaliated 
     against if such representative party has complained, in good 
     faith, about the quality of care provided by the facility or 
     other issues relating to the facility, and that a person who 
     works at a skilled nursing facility is not retaliated against 
     if the worker has complained, in good faith, about quality of 
     care or services or an issue relating to the quality of care 
     or services provided at the facility, whether the resident, 
     legal representative, other responsible party, or worker used 
     the form developed under subsection (f)(9) or some other 
     method for submitting the complaint. Such complaint 
     resolution process shall include--
       ``(i) procedures to assure accurate tracking of complaints 
     received, including notification to the complainant that a 
     complaint has been received;
       ``(ii) procedures to determine the likely severity of a 
     complaint and for the investigation of the complaint;
       ``(iii) deadlines for responding to a complaint and for 
     notifying the complainant of the outcome of the 
     investigation; and
       ``(iv) procedures to ensure that the identity of the 
     complainant will be kept confidential.
       ``(C) Whistleblower protection.--
       ``(i) Prohibition against retaliation.--No person who works 
     at a skilled nursing facility may be penalized, 
     discriminated, or retaliated against with respect to any 
     aspect of employment, including discharge, promotion, 
     compensation, terms, conditions, or privileges of employment, 
     or have a contract for services terminated, because the 
     person (or anyone acting at the person's request) complained, 
     in good faith, about the quality of care or services provided 
     by a skilled nursing facility or about other issues relating 
     to quality of care or services, whether using the form 
     developed under subsection (f)(9) or some other method for 
     submitting the complaint.
       ``(ii) Retaliatory reporting.--A skilled nursing facility 
     may not file a complaint or a report against a person who 
     works (or has worked at the facility) with the appropriate 
     State professional disciplinary agency because the person (or 
     anyone acting at the person's request) complained in good 
     faith, as described in clause (i).
       ``(iii) Relief.--Any person aggrieved by a violation of 
     clause (i) or clause (ii) may, in a civil action, obtain all 
     appropriate relief, including reinstatement, reimbursement of 
     lost wages, compensation, and benefits, and exemplary damages 
     where warranted, and such other relief as the court deems 
     appropriate, as well as costs of suit and reasonable attorney 
     and expert witness fees.
       ``(iv) Rights not waivable.--The rights protected by this 
     paragraph may not be diminished by contract or other 
     agreement, and nothing in this paragraph shall be construed 
     to diminish any greater or additional protection provided by 
     Federal or State law or by contract or other agreement.
       ``(v) Requirement to post notice of employee rights.--Each 
     skilled nursing facility shall post conspicuously in an 
     appropriate location a sign (in a form specified by the 
     Secretary) specifying the rights of persons under this 
     paragraph and including a statement that an employee may file 
     a complaint with the Secretary against a skilled nursing 
     facility that violates the provisions of this paragraph and 
     information with respect to the manner of filing such a 
     complaint.
       ``(D) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a resident of a skilled 
     nursing facility (or a person acting on the resident's 
     behalf) from submitting a complaint in a manner or format 
     other than by using the standardized complaint form developed 
     under subsection (f)(9) (including submitting a complaint 
     orally).
       ``(E) Good faith defined.--For purposes of this paragraph, 
     an individual shall be deemed to be acting in good faith with 
     respect to the filing of a complaint if the individual 
     reasonably believes--
       ``(i) the information reported or disclosed in the 
     complaint is true; and
       ``(ii) the violation of this title has occurred or may 
     occur in relation to such information.''.
       (b) Nursing Facilities.--
       (1) Development by the secretary.--Section 1919(f) of the 
     Social Security Act (42 U.S.C. 1395i-3(f)), as amended by 
     section 1413(b), is amended by adding at the end the 
     following new paragraph:
       ``(11) Standardized complaint form.--The Secretary shall 
     develop a standardized complaint form for use by a resident 
     (or a person acting on the resident's behalf) in filing a 
     complaint with a State survey and certification agency and a 
     State long-term care ombudsman program with respect to a 
     nursing facility.''.
       (2) State requirements.--Section 1919(e) of the Social 
     Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at 
     the end the following new paragraph:
       ``(8) Complaint processes and whistleblower protection.--
       ``(A) Complaint forms.--The State must make the 
     standardized complaint form developed under subsection 
     (f)(11) available upon request to--
       ``(i) a resident of a nursing facility;
       ``(ii) any person acting on the resident's behalf; and
       ``(iii) any person who works at a nursing facility or a 
     representative of such a worker.
       ``(B) Complaint resolution process.--The State must 
     establish a complaint resolution process in order to ensure 
     that a resident, the legal representative of a resident of a 
     nursing facility, or other responsible party is not 
     retaliated against if the resident, legal

[[Page 27304]]

     representative, or responsible party has complained, in good 
     faith, about the quality of care or other issues relating to 
     the nursing facility, that the legal representative of a 
     resident of a nursing facility or other responsible party is 
     not denied access to such resident or otherwise retaliated 
     against if such representative party has complained, in good 
     faith, about the quality of care provided by the facility or 
     other issues relating to the facility, and that a person who 
     works at a nursing facility is not retaliated against if the 
     worker has complained, in good faith, about quality of care 
     or services or an issue relating to the quality of care or 
     services provided at the facility, whether the resident, 
     legal representative, other responsible party, or worker used 
     the form developed under subsection (f)(11) or some other 
     method for submitting the complaint. Such complaint 
     resolution process shall include--
       ``(i) procedures to assure accurate tracking of complaints 
     received, including notification to the complainant that a 
     complaint has been received;
       ``(ii) procedures to determine the likely severity of a 
     complaint and for the investigation of the complaint;
       ``(iii) deadlines for responding to a complaint and for 
     notifying the complainant of the outcome of the 
     investigation; and
       ``(iv) procedures to ensure that the identity of the 
     complainant will be kept confidential.
       ``(C) Whistleblower protection.--
       ``(i) Prohibition against retaliation.--No person who works 
     at a nursing facility may be penalized, discriminated, or 
     retaliated against with respect to any aspect of employment, 
     including discharge, promotion, compensation, terms, 
     conditions, or privileges of employment, or have a contract 
     for services terminated, because the person (or anyone acting 
     at the person's request) complained, in good faith, about the 
     quality of care or services provided by a nursing facility or 
     about other issues relating to quality of care or services, 
     whether using the form developed under subsection (f)(11) or 
     some other method for submitting the complaint.
       ``(ii) Retaliatory reporting.--A nursing facility may not 
     file a complaint or a report against a person who works (or 
     has worked at the facility with the appropriate State 
     professional disciplinary agency because the person (or 
     anyone acting at the person's request) complained in good 
     faith, as described in clause (i).
       ``(iii) Relief.--Any person aggrieved by a violation of 
     clause (i) or clause (ii) may, in a civil action, obtain all 
     appropriate relief, including reinstatement, reimbursement of 
     lost wages, compensation, and benefits, and exemplary damages 
     where warranted, and such other relief as the court deems 
     appropriate, as well as costs of suit and reasonable attorney 
     and expert witness fees.
       ``(iv) Rights not waivable.--The rights protected by this 
     paragraph may not be diminished by contract or other 
     agreement, and nothing in this paragraph shall be construed 
     to diminish any greater or additional protection provided by 
     Federal or State law or by contract or other agreement.
       ``(v) Requirement to post notice of employee rights.--Each 
     nursing facility shall post conspicuously in an appropriate 
     location a sign (in a form specified by the Secretary) 
     specifying the rights of persons under this paragraph and 
     including a statement that an employee may file a complaint 
     with the Secretary against a nursing facility that violates 
     the provisions of this paragraph and information with respect 
     to the manner of filing such a complaint.
       ``(D) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a resident of a nursing 
     facility (or a person acting on the resident's behalf) from 
     submitting a complaint in a manner or format other than by 
     using the standardized complaint form developed under 
     subsection (f)(11) (including submitting a complaint orally).
       ``(E) Good faith defined.--For purposes of this paragraph, 
     an individual shall be deemed to be acting in good faith with 
     respect to the filing of a complaint if the individual 
     reasonably believes--
       ``(i) the information reported or disclosed in the 
     complaint is true; and
       ``(ii) the violation of this title has occurred or may 
     occur in relation to such information.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.

       (a) Skilled Nursing Facilities.--Section 1819(b)(8) of the 
     Social Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by 
     adding at the end the following new subparagraph:
       ``(C) Submission of staffing information based on payroll 
     data in a uniform format.--On and after the first day of the 
     first calendar quarter beginning after the date that is 2 
     years after the date of enactment of this subparagraph, and 
     after consulting with State long-term care ombudsman 
     programs, consumer advocacy groups, provider stakeholder 
     groups, employees and their representatives, and other 
     parties the Secretary deems appropriate, the Secretary shall 
     require a skilled nursing facility to electronically submit 
     to the Secretary direct care staffing information (including 
     information with respect to agency and contract staff) based 
     on payroll and other verifiable and auditable data in a 
     uniform format (according to specifications established by 
     the Secretary in consultation with such programs, groups, and 
     parties). Such specifications shall require that the 
     information submitted under the preceding sentence--
       ``(i) specify the category of work a certified employee 
     performs (such as whether the employee is a registered nurse, 
     licensed practical nurse, licensed vocational nurse, 
     certified nursing assistant, therapist, or other medical 
     personnel);
       ``(ii) include resident census data and information on 
     resident case mix;
       ``(iii) include a regular reporting schedule; and
       ``(iv) include information on employee turnover and tenure 
     and on the hours of care provided by each category of 
     certified employees referenced in clause (i) per resident per 
     day.
     Nothing in this subparagraph shall be construed as preventing 
     the Secretary from requiring submission of such information 
     with respect to specific categories, such as nursing staff, 
     before other categories of certified employees. Information 
     under this subparagraph with respect to agency and contract 
     staff shall be kept separate from information on employee 
     staffing.''.
       (b) Nursing Facilities.--Section 1919(b)(8) of the Social 
     Security Act (42 U.S.C. 1396r(b)(8)) is amended by adding at 
     the end the following new subparagraph:
       ``(C) Submission of staffing information based on payroll 
     data in a uniform format.--On and after the first day of the 
     first calendar quarter beginning after the date that is 2 
     years after the date of enactment of this subparagraph, and 
     after consulting with State long-term care ombudsman 
     programs, consumer advocacy groups, provider stakeholder 
     groups, employees and their representatives, and other 
     parties the Secretary deems appropriate, the Secretary shall 
     require a nursing facility to electronically submit to the 
     Secretary direct care staffing information (including 
     information with respect to agency and contract staff) based 
     on payroll and other verifiable and auditable data in a 
     uniform format (according to specifications established by 
     the Secretary in consultation with such programs, groups, and 
     parties). Such specifications shall require that the 
     information submitted under the preceding sentence--
       ``(i) specify the category of work a certified employee 
     performs (such as whether the employee is a registered nurse, 
     licensed practical nurse, licensed vocational nurse, 
     certified nursing assistant, therapist, or other medical 
     personnel);
       ``(ii) include resident census data and information on 
     resident case mix;
       ``(iii) include a regular reporting schedule; and
       ``(iv) include information on employee turnover and tenure 
     and on the hours of care provided by each category of 
     certified employees referenced in clause (i) per resident per 
     day.

     Nothing in this subparagraph shall be construed as preventing 
     the Secretary from requiring submission of such information 
     with respect to specific categories, such as nursing staff, 
     before other categories of certified employees. Information 
     under this subparagraph with respect to agency and contract 
     staff shall be kept separate from information on employee 
     staffing.''.

     SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND STATE 
                   BACKGROUND CHECKS ON DIRECT PATIENT ACCESS 
                   EMPLOYEES OF LONG-TERM CARE FACILITIES AND 
                   PROVIDERS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary''), shall 
     establish a program to identify efficient, effective, and 
     economical procedures for long term care facilities or 
     providers to conduct background checks on prospective direct 
     patient access employees on a nationwide basis (in this 
     subsection, such program shall be referred to as the 
     ``nationwide program''). The Secretary shall carry out the 
     nationwide program under similar terms and conditions as the 
     pilot program under section 307 of the Medicare Prescription 
     Drug, Improvement, and Modernization Act of 2003 (Public Law 
     108-173; 117 Stat. 2257), including the prohibition on hiring 
     abusive workers and the authorization of the imposition of 
     penalties by a participating State under subsections 
     (b)(3)(A) and (b)(6), respectively, of such section 307. The 
     program under this subsection shall contain the following 
     modifications to such pilot program:
       (1) Agreements.--
       (A) Newly participating states.--The Secretary shall enter 
     into agreements with each State--
       (i) that the Secretary has not entered into an agreement 
     with under subsection (c)(1) of such section 307;
       (ii) that agrees to conduct background checks under the 
     nationwide program on a Statewide basis; and
       (iii) that submits an application to the Secretary 
     containing such information and at such time as the Secretary 
     may specify.

     Under such an agreement a State may agree to cover and 
     reimburse each long-term care facility or provider for all 
     costs attributable

[[Page 27305]]

     to conducting background checks and screening described in 
     this subsection that were not otherwise required to be 
     conducted by such long-term care facility or provider before 
     the enactment of this subsection, except that Federal funding 
     with respect to such reimbursement shall be limited to the 
     amount made available to the State from funds under 
     subsection (b)(1).
       (B) Certain previously participating states.--The Secretary 
     shall enter into agreements with each State--
       (i) that the Secretary has entered into an agreement with 
     under such subsection (c)(1);
       (ii) that agrees to conduct background checks under the 
     nationwide program on a Statewide basis; and
       (iii) that submits an application to the Secretary 
     containing such information and at such time as the Secretary 
     may specify.

     Under such an agreement a State may agree to cover and 
     reimburse each long-term care facility or provider for all 
     costs attributable to conducting background checks and 
     screening described in this subsection that were not 
     otherwise required to be conducted by such long-term care 
     facility or provider before the enactment of this subsection, 
     except that Federal funding with respect to such 
     reimbursement shall be limited to the amount made available 
     to the State from funds under subsection (b)(1).
       (2) Nonapplication of selection criteria.--The selection 
     criteria required under subsection (c)(3)(B) of such section 
     307 shall not apply.
       (3) Required fingerprint check as part of criminal 
     background check.--The procedures established under 
     subsection (b)(1) of such section 307 shall--
       (A) require that the long-term care facility or provider 
     (or the designated agent of the long-term care facility or 
     provider) obtain State and national criminal or other 
     background checks on the prospective employee through such 
     means as the Secretary determines appropriate that utilize a 
     search of State-based abuse and neglect registries and 
     databases, including the abuse and neglect registries of 
     another State in the case where a prospective employee 
     previously resided in that State, State criminal history 
     records, the records of any proceedings in the State that may 
     contain disqualifying information about prospective employees 
     (such as proceedings conducted by State professional 
     licensing and disciplinary boards and State Medicaid Fraud 
     Control Units), and Federal criminal history records, 
     including a fingerprint check using the Integrated Automated 
     Fingerprint Identification System of the Federal Bureau of 
     Investigation; and
       (B) require States to describe and test methods that reduce 
     duplicative fingerprinting, including providing for the 
     development of ``rap back'' capability by the State such 
     that, if a direct patient access employee of a long-term care 
     facility or provider is convicted of a crime following the 
     initial criminal history background check conducted with 
     respect to such employee, and the employee's fingerprints 
     match the prints on file with the State law enforcement 
     department, the department will immediately inform the State 
     and the State will immediately inform the long-term care 
     facility or provider which employs the direct patient access 
     employee of such conviction.
       (4) State requirements.--An agreement entered into under 
     paragraph (1) shall require that a participating State--
       (A) be responsible for monitoring compliance with the 
     requirements of the nationwide program;
       (B) have procedures in place to--
       (i) conduct screening and criminal or other background 
     checks under the nationwide program in accordance with the 
     requirements of this section;
       (ii) monitor compliance by long-term care facilities and 
     providers with the procedures and requirements of the 
     nationwide program;
       (iii) as appropriate, provide for a provisional period of 
     employment by a long-term care facility or provider of a 
     direct patient access employee, not to exceed 60 days, 
     pending completion of the required criminal history 
     background check and, in the case where the employee has 
     appealed the results of such background check, pending 
     completion of the appeals process, during which the employee 
     shall be subject to direct on-site supervision (in accordance 
     with procedures established by the State to ensure that a 
     long-term care facility or provider furnishes such direct on-
     site supervision);
       (iv) provide an independent process by which a provisional 
     employee or an employee may appeal or dispute the accuracy of 
     the information obtained in a background check performed 
     under the nationwide program, including the specification of 
     criteria for appeals for direct patient access employees 
     found to have disqualifying information which shall include 
     consideration of the passage of time, extenuating 
     circumstances, demonstration of rehabilitation, and relevancy 
     of the particular disqualifying information with respect to 
     the current employment of the individual;
       (v) provide for the designation of a single State agency as 
     responsible for--

       (I) overseeing the coordination of any State and national 
     criminal history background checks requested by a long-term 
     care facility or provider (or the designated agent of the 
     long-term care facility or provider) utilizing a search of 
     State and Federal criminal history records, including a 
     fingerprint check of such records;
       (II) overseeing the design of appropriate privacy and 
     security safeguards for use in the review of the results of 
     any State or national criminal history background checks 
     conducted regarding a prospective direct patient access 
     employee to determine whether the employee has any conviction 
     for a relevant crime;
       (III) immediately reporting to the long-term care facility 
     or provider that requested the criminal history background 
     check the results of such review; and
       (IV) in the case of an employee with a conviction for a 
     relevant crime that is subject to reporting under section 
     1128E of the Social Security Act (42 U.S.C. 1320a-7e), 
     reporting the existence of such conviction to the database 
     established under that section;

       (vi) determine which individuals are direct patient access 
     employees (as defined in paragraph (6)(B)) for purposes of 
     the nationwide program;
       (vii) as appropriate, specify offenses, including 
     convictions for violent crimes, for purposes of the 
     nationwide program; and
       (viii) describe and test methods that reduce duplicative 
     fingerprinting, including providing for the development of 
     ``rap back'' capability such that, if a direct patient access 
     employee of a long-term care facility or provider is 
     convicted of a crime following the initial criminal history 
     background check conducted with respect to such employee, and 
     the employee's fingerprints match the prints on file with the 
     State law enforcement department--

       (I) the department will immediately inform the State agency 
     designated under clause (v) and such agency will immediately 
     inform the facility or provider which employs the direct 
     patient access employee of such conviction; and
       (II) the State will provide, or will require the facility 
     to provide, to the employee a copy of the results of the 
     criminal history background check conducted with respect to 
     the employee at no charge in the case where the individual 
     requests such a copy.

     Background checks and screenings under this subsection shall 
     be valid for a period of no longer than 2 years, as 
     determined by the State and approved by the Secretary.
       (5) Payments.--
       (A) Newly participating states.--
       (i) In general.--As part of the application submitted by a 
     State under paragraph (1)(A)(iii), the State shall guarantee, 
     with respect to the costs to be incurred by the State in 
     carrying out the nationwide program, that the State will make 
     available (directly or through donations from public or 
     private entities) a particular amount of non-Federal 
     contributions, as a condition of receiving the Federal match 
     under clause (ii).
       (ii) Federal match.--The payment amount to each State that 
     the Secretary enters into an agreement with under paragraph 
     (1)(A) shall be 3 times the amount that the State guarantees 
     to make available under clause (i).
       (B) Previously participating states.--
       (i) In general.--As part of the application submitted by a 
     State under paragraph (1)(B)(iii), the State shall guarantee, 
     with respect to the costs to be incurred by the State in 
     carrying out the nationwide program, that the State will make 
     available (directly or through donations from public or 
     private entities) a particular amount of non-Federal 
     contributions, as a condition of receiving the Federal match 
     under clause (ii).
       (ii) Federal match.--The payment amount to each State that 
     the Secretary enters into an agreement with under paragraph 
     (1)(B) shall be 3 times the amount that the State guarantees 
     to make available under clause (i).
       (6) Definitions.--Under the nationwide program:
       (A) Long-term care facility or provider.--The term ``long-
     term care facility or provider'' means the following 
     facilities or providers which receive payment for services 
     under title XVIII or XIX of the Social Security Act:
       (i) A skilled nursing facility (as defined in section 
     1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a))).
       (ii) A nursing facility (as defined in section 1919(a) of 
     such Act (42 U.S.C. 1396r(a))).
       (iii) A home health agency.
       (iv) A provider of hospice care (as defined in section 
     1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))).
       (v) A long-term care hospital (as described in section 
     1886(d)(1)(B)(iv) of such Act (42 U.S.C. 
     1395ww(d)(1)(B)(iv))).
       (vi) A provider of personal care services.
       (vii) A provider of adult day care.
       (viii) A residential care provider that arranges for, or 
     directly provides, long-term care services, including an 
     assisted living facility that provides a nursing home level 
     of care conveyed by State licensure or State definition.
       (ix) An intermediate care facility for the mentally 
     retarded (as defined in section 1905(d) of such Act (42 
     U.S.C. 1396d(d))).
       (x) Any other facility or provider of long-term care 
     services under such titles as the participating State 
     determines appropriate.
       (B) Direct patient access employee.--The term ``direct 
     patient access employee''

[[Page 27306]]

     means any individual who has access to a patient or resident 
     of a long-term care facility or provider through employment 
     or through a contract with such facility or provider and has 
     duties that involve (or may involve) one-on-one contact with 
     a patient or resident of the facility or provider, as 
     determined by the State for purposes of the nationwide 
     program. Such term does not include a volunteer unless the 
     volunteer has duties that are equivalent to the duties of a 
     direct patient access employee and those duties involve (or 
     may involve) one-on-one contact with a patient or resident of 
     the long-term care facility or provider.
       (7) Evaluation and report.--
       (A) Evaluation.--The Inspector General of the Department of 
     Health and Human Services shall conduct an evaluation of the 
     nationwide program. Such evaluation shall include--
       (i) a review of the various procedures implemented by 
     participating States for long-term care facilities or 
     providers, including staffing agencies, to conduct background 
     checks of direct patient access employees and identify the 
     most efficient, effective, and economical procedures for 
     conducting such background checks;
       (ii) an assessment of the costs of conducting such 
     background checks (including start-up and administrative 
     costs);
       (iii) a determination of the extent to which conducting 
     such background checks leads to any unintended consequences, 
     including a reduction in the available workforce for such 
     facilities or providers;
       (iv) an assessment of the impact of the program on reducing 
     the number of incidents of neglect, abuse, and 
     misappropriation of resident property to the extent 
     practicable; and
       (v) an evaluation of other aspects of the program, as 
     determined appropriate by the Secretary.
       (B) Report.--Not later than 180 days after the completion 
     of the nationwide program, the Inspector General of the 
     Department of Health and Human Services shall submit a report 
     to Congress containing the results of the evaluation 
     conducted under subparagraph (A).
       (b) Funding.--
       (1) Notification.--The Secretary of Health and Human 
     Services shall notify the Secretary of the Treasury of the 
     amount necessary to carry out the nationwide program under 
     this section, including costs for the Department of Health 
     and Human Services to administer and evaluate the program, 
     for the period of fiscal years 2010 through 2012, except that 
     in no case shall such amount exceed $160,000,000.
       (2) Transfer of funds.--Out of any funds in the Treasury 
     not otherwise appropriated, the Secretary of the Treasury 
     shall provide for the transfer to the Secretary of Health and 
     Human Services of the amount specified as necessary to carry 
     out the nationwide program under paragraph (1). Such amount 
     shall remain available until expended.

                     PART 2--TARGETING ENFORCEMENT

     SEC. 1421. CIVIL MONEY PENALTIES.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819(h)(2)(B)(ii) of the Social 
     Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to 
     read as follows:
       ``(ii) Authority with respect to civil money penalties.--

       ``(I) Amount.--The Secretary may impose a civil money 
     penalty in the applicable per instance or per day amount (as 
     defined in subclause (II) and (III)) for each day or 
     instance, respectively, of noncompliance (as determined 
     appropriate by the Secretary).
       ``(II) Applicable per instance amount.--In this clause, the 
     term `applicable per instance amount' means--

       ``(aa) in the case where the deficiency is found to be a 
     direct proximate cause of death of a resident of the 
     facility, an amount not to exceed $100,000.
       ``(bb) in each case of a deficiency where the facility is 
     cited for actual harm or immediate jeopardy, an amount not 
     less than $3,050 and not more than $25,000; and
       ``(cc) in each case of any other deficiency, an amount not 
     less than $250 and not to exceed $3050.

       ``(III) Applicable per day amount.--In this clause, the 
     term `applicable per day amount' means--

       ``(aa) in each case of a deficiency where the facility is 
     cited for actual harm or immediate jeopardy, an amount not 
     less than $3,050 and not more than $25,000 and
       ``(bb) in each case of any other deficiency, an amount not 
     less than $250 and not to exceed $3,050.

       ``(IV) Reduction of civil money penalties in certain 
     circumstances.--Subject to subclauses (V) and (VI), in the 
     case where a facility self-reports and promptly corrects a 
     deficiency for which a penalty was imposed under this clause 
     not later than 10 calendar days after the date of such 
     imposition, the Secretary may reduce the amount of the 
     penalty imposed by not more than 50 percent.
       ``(V) Prohibition on reduction for certain deficiencies.--

       ``(aa) Repeat deficiencies.--The Secretary may not reduce 
     under subclause (IV) the amount of a penalty if the 
     deficiency is a repeat deficiency.
       ``(bb) Certain other deficiencies.--The Secretary may not 
     reduce under subclause (IV) the amount of a penalty if the 
     penalty is imposed for a deficiency described in subclause 
     (II)(aa) or (III)(aa) and the actual harm or widespread harm 
     immediately jeopardizes the health or safety of a resident or 
     residents of the facility, or if the penalty is imposed for a 
     deficiency described in subclause (II)(bb).

       ``(VI) Limitation on aggregate reductions.--The aggregate 
     reduction in a penalty under subclause (IV) may not exceed 35 
     percent on the basis of self-reporting, on the basis of a 
     waiver of an appeal (as provided for under regulations under 
     section 488.436 of title 42, Code of Federal Regulations), or 
     on the basis of both.
       ``(VII) Collection of civil money penalties.--In the case 
     of a civil money penalty imposed under this clause, the 
     Secretary--

       ``(aa) subject to item (cc), shall, not later than 30 days 
     after the date of imposition of the penalty, provide the 
     opportunity for the facility to participate in an independent 
     informal dispute resolution process, established by the State 
     survey agency, which generates a written record prior to the 
     collection of such penalty, but such opportunity shall not 
     affect the responsibility of the State survey agency for 
     making final recommendations for such penalties;
       ``(bb) in the case where the penalty is imposed for each 
     day of noncompliance, shall not impose a penalty for any day 
     during the period beginning on the initial day of the 
     imposition of the penalty and ending on the day on which the 
     informal dispute resolution process under item (aa) is 
     completed;
       ``(cc) may provide for the collection of such civil money 
     penalty and the placement of such amounts collected in an 
     escrow account under the direction of the Secretary on the 
     earlier of the date on which the informal dispute resolution 
     process under item (aa) is completed or the date that is 90 
     days after the date of the imposition of the penalty;
       ``(dd) may provide that such amounts collected are kept in 
     such account pending the resolution of any subsequent 
     appeals;
       ``(ee) in the case where the facility successfully appeals 
     the penalty, may provide for the return of such amounts 
     collected (plus interest) to the facility; and
       ``(ff) in the case where all such appeals are unsuccessful, 
     may provide that some portion of such amounts collected may 
     be used to support activities that benefit residents, 
     including assistance to support and protect residents of a 
     facility that closes (voluntarily or involuntarily) or is 
     decertified (including offsetting costs of relocating 
     residents to home and community-based settings or another 
     facility), projects that support resident and family councils 
     and other consumer involvement in assuring quality care in 
     facilities, and facility improvement initiatives approved by 
     the Secretary (including joint training of facility staff and 
     surveyors, technical assistance for facilities under quality 
     assurance programs, the appointment of temporary management, 
     and other activities approved by the Secretary).

       ``(VIII) Procedure.--The provisions of section 1128A (other 
     than subsections (a) and (b) and except to the extent that 
     such provisions require a hearing prior to the imposition of 
     a civil money penalty) shall apply to a civil money penalty 
     under this clause in the same manner as such provisions apply 
     to a penalty or proceeding under section 1128A(a).''.

       (2) Conforming amendment.--The second sentence of section 
     1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-
     3(h)(5)) is amended by inserting ``(ii),''after ``(i),''.
       (b) Nursing Facilities.--
       (1) Penalties imposed by the state.--
       (A) In general.--Section 1919(h)(2) of the Social Security 
     Act (42 U.S.C. 1396r(h)(2)) is amended--
       (i) in subparagraph (A)(ii), by striking the first sentence 
     and inserting the following: ``A civil money penalty in 
     accordance with subparagraph (G).''; and
       (ii) by adding at the end the following new subparagraph:
       ``(G) Civil money penalties.--
       ``(i) In general.--The State may impose a civil money 
     penalty under subparagraph (A)(ii) in the applicable per 
     instance or per day amount (as defined in subclause (II) and 
     (III)) for each day or instance, respectively, of 
     noncompliance (as determined appropriate by the Secretary).
       ``(ii) Applicable per instance amount.--In this 
     subparagraph, the term `applicable per instance amount' 
     means--

       ``(I) in the case where the deficiency is found to be a 
     direct proximate cause of death of a resident of the 
     facility, an amount not to exceed $100,000.
       ``(II) in each case of a deficiency where the facility is 
     cited for actual harm or immediate jeopardy, an amount not 
     less than $3,050 and not more than $25,000; and
       ``(III) in each case of any other deficiency, an amount not 
     less than $250 and not to exceed $3050.

       ``(iii) Applicable per day amount.--In this subparagraph, 
     the term `applicable per day amount' means--

       ``(I) in each case of a deficiency where the facility is 
     cited for actual harm or immediate jeopardy, an amount not 
     less than $3,050 and not more than $25,000 and
       ``(II) in each case of any other deficiency, an amount not 
     less than $250 and not to exceed $3,050.

[[Page 27307]]

       ``(iv) Reduction of civil money penalties in certain 
     circumstances.--Subject to clauses (v) and (vi), in the case 
     where a facility self-reports and promptly corrects a 
     deficiency for which a penalty was imposed under subparagraph 
     (A)(ii) not later than 10 calendar days after the date of 
     such imposition, the State may reduce the amount of the 
     penalty imposed by not more than 50 percent.
       ``(v) Prohibition on reduction for certain deficiencies.--

       ``(I) Repeat deficiencies.--The State may not reduce under 
     clause (iv) the amount of a penalty if the State had reduced 
     a penalty imposed on the facility in the preceding year under 
     such clause with respect to a repeat deficiency.
       ``(II) Certain other deficiencies.--The State may not 
     reduce under clause (iv) the amount of a penalty if the 
     penalty is imposed for a deficiency described in clause 
     (ii)(II) or (iii)(I) and the actual harm or widespread harm 
     that immediately jeopardizes the health or safety of a 
     resident or residents of the facility, or if the penalty is 
     imposed for a deficiency described in clause (ii)(I).
       ``(III) Limitation on aggregate reductions.--The aggregate 
     reduction in a penalty under clause (iv) may not exceed 35 
     percent on the basis of self-reporting, on the basis of a 
     waiver of an appeal (as provided for under regulations under 
     section 488.436 of title 42, Code of Federal Regulations), or 
     on the basis of both.

       ``(vi) Collection of civil money penalties.--In the case of 
     a civil money penalty imposed under subparagraph (A)(ii), the 
     State--

       ``(I) subject to subclause (III), shall, not later than 30 
     days after the date of imposition of the penalty, provide the 
     opportunity for the facility to participate in an independent 
     informal dispute resolution process, established by the State 
     survey agency, which generates a written record prior to the 
     collection of such penalty, but such opportunity shall not 
     affect the responsibility of the State survey agency for 
     making final recommendations for such penalties;
       ``(II) in the case where the penalty is imposed for each 
     day of noncompliance, shall not impose a penalty for any day 
     during the period beginning on the initial day of the 
     imposition of the penalty and ending on the day on which the 
     informal dispute resolution process under subclause (I) is 
     completed;
       ``(III) may provide for the collection of such civil money 
     penalty and the placement of such amounts collected in an 
     escrow account under the direction of the State on the 
     earlier of the date on which the informal dispute resolution 
     process under subclause (I) is completed or the date that is 
     90 days after the date of the imposition of the penalty;
       ``(IV) may provide that such amounts collected are kept in 
     such account pending the resolution of any subsequent 
     appeals;
       ``(V) in the case where the facility successfully appeals 
     the penalty, may provide for the return of such amounts 
     collected (plus interest) to the facility; and
       ``(VI) in the case where all such appeals are unsuccessful, 
     may provide that such funds collected shall be used for the 
     purposes described in the second sentence of subparagraph 
     (A)(ii).''.

       (B) Conforming amendment.--The second sentence of section 
     1919(h)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
     1396r(h)(2)(A)(ii)) is amended by inserting before the period 
     at the end the following: ``, and some portion of such funds 
     may be used to support activities that benefit residents, 
     including assistance to support and protect residents of a 
     facility that closes (voluntarily or involuntarily) or is 
     decertified (including offsetting costs of relocating 
     residents to home and community-based settings or another 
     facility), projects that support resident and family councils 
     and other consumer involvement in assuring quality care in 
     facilities, and facility improvement initiatives approved by 
     the Secretary (including joint training of facility staff and 
     surveyors, providing technical assistance to facilities under 
     quality assurance programs, the appointment of temporary 
     management, and other activities approved by the 
     Secretary)''.
       (2) Penalties imposed by the secretary.--
       (A) In general.--Section 1919(h)(3)(C)(ii) of the Social 
     Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended to read as 
     follows:
       ``(ii) Authority with respect to civil money penalties.--

       ``(I) Amount.--Subject to subclause (II), the Secretary may 
     impose a civil money penalty in an amount not to exceed 
     $10,000 for each day or each instance of noncompliance (as 
     determined appropriate by the Secretary).
       ``(II) Reduction of civil money penalties in certain 
     circumstances.--Subject to subclause (III), in the case where 
     a facility self-reports and promptly corrects a deficiency 
     for which a penalty was imposed under this clause not later 
     than 10 calendar days after the date of such imposition, the 
     Secretary may reduce the amount of the penalty imposed by not 
     more than 50 percent.
       ``(III) Prohibition on reduction for repeat deficiencies.--
     The Secretary may not reduce the amount of a penalty under 
     subclause (II) if the Secretary had reduced a penalty imposed 
     on the facility in the preceding year under such subclause 
     with respect to a repeat deficiency.
       ``(IV) Collection of civil money penalties.--In the case of 
     a civil money penalty imposed under this clause, the 
     Secretary--

       ``(aa) subject to item (bb), shall, not later than 30 days 
     after the date of imposition of the penalty, provide the 
     opportunity for the facility to participate in an independent 
     informal dispute resolution process which generates a written 
     record prior to the collection of such penalty;
       ``(bb) in the case where the penalty is imposed for each 
     day of noncompliance, shall not impose a penalty for any day 
     during the period beginning on the initial day of the 
     imposition of the penalty and ending on the day on which the 
     informal dispute resolution process under item (aa) is 
     completed;
       ``(cc) may provide for the collection of such civil money 
     penalty and the placement of such amounts collected in an 
     escrow account under the direction of the Secretary on the 
     earlier of the date on which the informal dispute resolution 
     process under item (aa) is completed or the date that is 90 
     days after the date of the imposition of the penalty;
       ``(dd) may provide that such amounts collected are kept in 
     such account pending the resolution of any subsequent 
     appeals;
       ``(ee) in the case where the facility successfully appeals 
     the penalty, may provide for the return of such amounts 
     collected (plus interest) to the facility; and
       ``(ff) in the case where all such appeals are unsuccessful, 
     may provide that some portion of such amounts collected may 
     be used to support activities that benefit residents, 
     including assistance to support and protect residents of a 
     facility that closes (voluntarily or involuntarily) or is 
     decertified (including offsetting costs of relocating 
     residents to home and community-based settings or another 
     facility), projects that support resident and family councils 
     and other consumer involvement in assuring quality care in 
     facilities, and facility improvement initiatives approved by 
     the Secretary (including joint training of facility staff and 
     surveyors, technical assistance for facilities under quality 
     assurance programs, the appointment of temporary management, 
     and other activities approved by the Secretary).

       ``(V) Procedure.--The provisions of section 1128A (other 
     than subsections (a) and (b) and except to the extent that 
     such provisions require a hearing prior to the imposition of 
     a civil money penalty) shall apply to a civil money penalty 
     under this clause in the same manner as such provisions apply 
     to a penalty or proceeding under section 1128A(a).''.

       (B) Conforming amendment.--Section 1919(h)(8) of the Social 
     Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by 
     inserting ``and in paragraph (3)(C)(ii)'' after ``paragraph 
     (2)(A)''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.

       (a) Establishment.--
       (1) In general.--The Secretary, in consultation with the 
     Inspector General of the Department of Health and Human 
     Services, shall establish a pilot program (in this section 
     referred to as the ``pilot program'') to develop, test, and 
     implement use of an independent monitor to oversee interstate 
     and large intrastate chains of skilled nursing facilities and 
     nursing facilities.
       (2) Selection.--The Secretary shall select chains of 
     skilled nursing facilities and nursing facilities described 
     in paragraph (1) to participate in the pilot program from 
     among those chains that submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       (3) Duration.--The Secretary shall conduct the pilot 
     program for a two-year period.
       (4) Implementation.--The Secretary shall implement the 
     pilot program not later than one year after the date of the 
     enactment of this Act.
       (b) Requirements.--The Secretary shall evaluate chains 
     selected to participate in the pilot program based on 
     criteria selected by the Secretary, including where evidence 
     suggests that one or more facilities of the chain are 
     experiencing serious safety and quality of care problems. 
     Such criteria may include the evaluation of a chain that 
     includes one or more facilities participating in the 
     ``Special Focus Facility'' program (or a successor program) 
     or one or more facilities with a record of repeated serious 
     safety and quality of care deficiencies.
       (c) Responsibilities of the Independent Monitor.--An 
     independent monitor that enters into a contract with the 
     Secretary to participate in the conduct of such program 
     shall--
       (1) conduct periodic reviews and prepare root-cause quality 
     and deficiency analyses of a chain to assess if facilities of 
     the chain are in compliance with State and Federal laws and 
     regulations applicable to the facilities;
       (2) undertake sustained oversight of the chain, whether 
     publicly or privately held, to involve the owners of the 
     chain and the principal business partners of such owners in 
     facilitating compliance by facilities of the chain with State 
     and Federal laws and regulations applicable to the 
     facilities;

[[Page 27308]]

       (3) analyze the management structure, distribution of 
     expenditures, and nurse staffing levels of facilities of the 
     chain in relation to resident census, staff turnover rates, 
     and tenure;
       (4) report findings and recommendations with respect to 
     such reviews, analyses, and oversight to the chain and 
     facilities of the chain, to the Secretary and to relevant 
     States; and
       (5) publish the results of such reviews, analyses, and 
     oversight.
       (d) Implementation of Recommendations.--
       (1) Receipt of finding by chain.--Not later than 10 days 
     after receipt of a finding of an independent monitor under 
     subsection (c)(4), a chain participating in the pilot program 
     shall submit to the independent monitor a report--
       (A) outlining corrective actions the chain will take to 
     implement the recommendations in such report; or
       (B) indicating that the chain will not implement such 
     recommendations and why it will not do so.
       (2) Receipt of report by independent monitor.--Not later 
     than 10 days after the date of receipt of a report submitted 
     by a chain under paragraph (1), an independent monitor shall 
     finalize its recommendations and submit a report to the chain 
     and facilities of the chain, the Secretary, and the State (or 
     States) involved, as appropriate, containing such final 
     recommendations.
       (e) Cost of Appointment.--A chain shall be responsible for 
     a portion of the costs associated with the appointment of 
     independent monitors under the pilot program. The chain shall 
     pay such portion to the Secretary (in an amount and in 
     accordance with procedures established by the Secretary).
       (f) Waiver Authority.--The Secretary may waive such 
     requirements of titles XVIII and XIX of the Social Security 
     Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be 
     necessary for the purpose of carrying out the pilot program.
       (g) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.
       (h) Definitions.--In this section:
       (1) Facility.--The term ``facility'' means a skilled 
     nursing facility or a nursing facility.
       (2) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (3) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services, acting through the Assistant 
     Secretary for Planning and Evaluation.
       (4) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395(a)).
       (i) Evaluation and Report.--
       (1) Evaluation.--The Inspector General of the Department of 
     Health and Human Services shall evaluate the pilot program. 
     Such evaluation shall--
       (A) determine whether the independent monitor program 
     should be established on a permanent basis; and
       (B) if the Inspector General determines that the 
     independent monitor program should be established on a 
     permanent basis, recommend appropriate procedures and 
     mechanisms for such establishment.
       (2) Report.--Not later than 180 days after the completion 
     of the pilot program, the Inspector General shall submit to 
     Congress and the Secretary a report containing the results of 
     the evaluation conducted under paragraph (1), together with 
     recommendations for such legislation and administrative 
     action as the Inspector General determines appropriate.

     SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.

       (a) Skilled Nursing Facilities.--
       (1) In general.--Section 1819(c) of the Social Security Act 
     (42 U.S.C. 1395i-3(c)) is amended by adding at the end the 
     following new paragraph:
       ``(7) Notification of facility closure.--
       ``(A) In general.--Any individual who is the administrator 
     of a skilled nursing facility must--
       ``(i) submit to the Secretary, the State long-term care 
     ombudsman, residents of the facility, and the legal 
     representatives of such residents or other responsible 
     parties, written notification of an impending closure--

       ``(I) subject to subclause (II), not later than the date 
     that is 60 days prior to the date of such closure; and
       ``(II) in the case of a facility where the Secretary 
     terminates the facility's participation under this title, not 
     later than the date that the Secretary determines 
     appropriate;

       ``(ii) ensure that the facility does not admit any new 
     residents on or after the date on which such written 
     notification is submitted; and
       ``(iii) include in the notice a plan for the transfer and 
     adequate relocation of the residents of the facility by a 
     specified date prior to closure that has been approved by the 
     State, including assurances that the residents will be 
     transferred to the most appropriate facility or other setting 
     in terms of quality, services, and location, taking into 
     consideration the needs and best interests of each resident.
       ``(B) Relocation.--
       ``(i) In general.--The State shall ensure that, before a 
     facility closes, all residents of the facility have been 
     successfully relocated to another facility or an alternative 
     home and community-based setting.
       ``(ii) Continuation of payments until residents 
     relocated.--The Secretary may, as the Secretary determines 
     appropriate, continue to make payments under this title with 
     respect to residents of a facility that has submitted a 
     notification under subparagraph (A) during the period 
     beginning on the date such notification is submitted and 
     ending on the date on which the resident is successfully 
     relocated.''.
       (2) Conforming amendments.--Section 1819(h)(4) of the 
     Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
       (A) in the first sentence, by striking ``the Secretary 
     shall terminate'' and inserting ``the Secretary, subject to 
     subsection (c)(7), shall terminate''; and
       (B) in the second sentence, by striking ``subsection 
     (c)(2)'' and inserting ``paragraphs (2) and (7) of subsection 
     (c)''.
       (b) Nursing Facilities.--
       (1) In general.--Section 1919(c) of the Social Security Act 
     (42 U.S.C. 1396r(c)) is amended by adding at the end the 
     following new paragraph:
       ``(9) Notification of facility closure.--
       ``(A) In general.--Any individual who is an administrator 
     of a nursing facility must--
       ``(i) submit to the Secretary, the State long-term care 
     ombudsman, residents of the facility, and the legal 
     representatives of such residents or other responsible 
     parties, written notification of an impending closure--

       ``(I) subject to subclause (II), not later than the date 
     that is 60 days prior to the date of such closure; and
       ``(II) in the case of a facility where the Secretary 
     terminates the facility's participation under this title, not 
     later than the date that the Secretary determines 
     appropriate;

       ``(ii) ensure that the facility does not admit any new 
     residents on or after the date on which such written 
     notification is submitted; and
       ``(iii) include in the notice a plan for the transfer and 
     adequate relocation of the residents of the facility by a 
     specified date prior to closure that has been approved by the 
     State, including assurances that the residents will be 
     transferred to the most appropriate facility or other setting 
     in terms of quality, services, and location, taking into 
     consideration the needs and best interests of each resident.
       ``(B) Relocation.--
       ``(i) In general.--The State shall ensure that, before a 
     facility closes, all residents of the facility have been 
     successfully relocated to another facility or an alternative 
     home and community-based setting.
       ``(ii) Continuation of payments until residents 
     relocated.--The Secretary may, as the Secretary determines 
     appropriate, continue to make payments under this title with 
     respect to residents of a facility that has submitted a 
     notification under subparagraph (A) during the period 
     beginning on the date such notification is submitted and 
     ending on the date on which the resident is successfully 
     relocated.''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

                    PART 3--IMPROVING STAFF TRAINING

     SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.

       (a) Skilled Nursing Facilities.--Section 
     1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 
     1395i-3(f)(2)(A)(i)(I)) is amended by inserting ``(including, 
     in the case of initial training and, if the Secretary 
     determines appropriate, in the case of ongoing training, 
     dementia management training and resident abuse prevention 
     training)'' after ``curriculum''.
       (b) Nursing Facilities.--Section 1919(f)(2)(A)(i)(I) of the 
     Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is 
     amended by inserting ``(including, in the case of initial 
     training and, if the Secretary determines appropriate, in the 
     case of ongoing training, dementia management training and 
     resident abuse prevention training)'' after ``curriculum''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect 1 year after the date of the enactment of 
     this Act.

     SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR 
                   CERTIFIED NURSE AIDES AND SUPERVISORY STAFF.

       (a) Study.--
       (1) In general.--The Secretary shall conduct a study on the 
     content of training for certified nurse aides and supervisory 
     staff of skilled nursing facilities and nursing facilities. 
     The study shall include an analysis of the following:
       (A) Whether the number of initial training hours for 
     certified nurse aides required under sections 
     1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the Social 
     Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II); 
     1396r(f)(2)(A)(i)(II)) should be increased from 75 and, if 
     so, what the required number of initial training hours should 
     be, including any recommendations for the content of such 
     training (including training related to dementia).
       (B) Whether requirements for ongoing training under such 
     sections 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) should 
     be increased from 12 hours per year,

[[Page 27309]]

     including any recommendations for the content of such 
     training.
       (2) Consultation.--In conducting the analysis under 
     paragraph (1)(A), the Secretary shall consult with States 
     that, as of the date of the enactment of this Act, require 
     more than 75 hours of training for certified nurse aides.
       (3) Definitions.--In this section:
       (A) Nursing facility.--The term ``nursing facility'' has 
     the meaning given such term in section 1919(a) of the Social 
     Security Act (42 U.S.C. 1396r(a)).
       (B) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services, acting through the Assistant 
     Secretary for Planning and Evaluation.
       (C) Skilled nursing facility.--The term ``skilled nursing 
     facility'' has the meaning given such term in section 1819(a) 
     of the Social Security Act (42 U.S.C. 1395(a)).
       (b) Report.--Not later than 2 years after the date of the 
     enactment of this Act, the Secretary shall submit to Congress 
     a report containing the results of the study conducted under 
     subsection (a), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.

     SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERVICES OF A 
                   SKILLED NURSING FACILITY OR NURSING FACILITY.

       (a) Medicare.--Section 1819(b)(4)(A) of the Social Security 
     Act (42 U.S.C. 1395i-3(b)(4)(A)) is amended by adding at the 
     end the following: ``With respect to meeting the staffing 
     requirement imposed by the Secretary to carry out clause 
     (iv), the full-time director of food services of the 
     facility, if not a qualified dietitian (as defined in section 
     483.35(a)(2) of title 42, Code of Federal Regulations, as in 
     effect as of the date of the enactment of this sentence), 
     shall be a Certified Dietary Manager meeting the requirements 
     of the Certifying Board for Dietary Managers, or a Dietetic 
     Technician, Registered meeting the requirements of the 
     Commission on Dietetic Registration or have equivalent 
     military, academic, or other qualifications (as specified by 
     the Secretary).''.
       (b) Medicaid.--Section 1919(b)(4)(A) of the Social Security 
     Act (42 U.S.C. 1396r(b)(4)(A)) is amended by adding at the 
     end the following: ``With respect to meeting the staffing 
     requirement imposed by the Secretary to carry out clause 
     (iv), the full-time director of food services of the 
     facility, if not a qualified dietitian (as defined in section 
     483.35(a)(2) of title 42, Code of Federal Regulations, as in 
     effect as of the date of the enactment of this sentence), 
     shall be a Certified Dietary Manager meeting the requirements 
     of the Certifying Board for Dietary Managers, or a Dietetic 
     Technician, Registered meeting the requirements of the 
     Commission on Dietetic Registration or have equivalent 
     military, academic, or other qualifications (as specified by 
     the Secretary).''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on the date that is 180 days after the date 
     of enactment of this Act.

                    Subtitle C--Quality Measurements

     SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY 
                   IMPROVEMENT.

       Title XI of the Social Security Act, as amended by section 
     1401(a), is further amended by adding at the end the 
     following new part:

                     ``Part E--Quality Improvement


   ``establishment of national priorities for performance improvement

       ``Sec. 1191.  (a) Establishment of National Priorities by 
     the Secretary.--The Secretary shall establish and 
     periodically update, not less frequently than triennially, 
     national priorities for performance improvement.
       ``(b) Recommendations for National Priorities.--In 
     establishing and updating national priorities under 
     subsection (a), the Secretary shall solicit and consider 
     recommendations from multiple outside stakeholders.
       ``(c) Considerations in Setting National Priorities.--With 
     respect to such priorities, the Secretary shall ensure that 
     priority is given to areas in the delivery of health care 
     services in the United States that--
       ``(1) contribute to a large burden of disease, including 
     those that address the health care provided to patients with 
     prevalent, high-cost chronic diseases;
       ``(2) have the greatest potential to decrease morbidity and 
     mortality in this country, including those that are designed 
     to eliminate harm to patients;
       ``(3) have the greatest potential for improving the 
     performance, affordability, and patient-centeredness of 
     health care, including those due to variations in care;
       ``(4) address health disparities across groups and areas; 
     and
       ``(5) have the potential for rapid improvement due to 
     existing evidence, standards of care or other reasons.
       ``(d) Definitions.--In this part:
       ``(1) Consensus-based entity.--The term `consensus-based 
     entity' means an entity with a contract with the Secretary 
     under section 1890.
       ``(2) Quality measure.--The term `quality measure' means a 
     national consensus standard for measuring the performance and 
     improvement of population health, or of institutional 
     providers of services, physicians, and other health care 
     practitioners in the delivery of health care services.
       ``(e) Funding.--
       ``(1) In general.--The Secretary shall provide for the 
     transfer, from the Federal Hospital Insurance Trust Fund 
     under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841 (in such proportion 
     as the Secretary determines appropriate), of $2,000,000, for 
     the activities under this section for each of the fiscal 
     years 2010 through 2014.
       ``(2) Authorization of appropriations.--For purposes of 
     carrying out the provisions of this section, in addition to 
     funds otherwise available, out of any funds in the Treasury 
     not otherwise appropriated, there are appropriated to the 
     Secretary of Health and Human Services $2,000,000 for each of 
     the fiscal years 2010 through 2014.''.

     SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO 
                   EVALUATION OF DATA COLLECTION PROCESS FOR 
                   QUALITY MEASUREMENT.

       Part E of title XI of the Social Security Act, as added by 
     section 1441, is amended by adding at the end the following 
     new sections:

     ``SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.

       ``(a) Agreements With Qualified Entities.--
       ``(1) In general.--The Secretary shall enter into 
     agreements with qualified entities to develop quality 
     measures for the delivery of health care services in the 
     United States.
       ``(2) Form of agreements.--The Secretary may carry out 
     paragraph (1) by contract, grant, or otherwise.
       ``(3) Recommendations of consensus-based entity.--In 
     carrying out this section, the Secretary shall--
       ``(A) seek public input; and
       ``(B) take into consideration recommendations of the 
     consensus-based entity with a contract with the Secretary 
     under section 1890(a).
       ``(b) Determination of Areas Where Quality Measures Are 
     Required.--Consistent with the national priorities 
     established under this part and with the programs 
     administered by the Centers for Medicare & Medicaid Services 
     and in consultation with other relevant Federal agencies, the 
     Secretary shall determine areas in which quality measures for 
     assessing health care services in the United States are 
     needed.
       ``(c) Development of Quality Measures.--
       ``(1) Patient-centered and population-based measures.--In 
     entering into agreements under subsection (a), the Secretary 
     shall give priority to the development of quality measures 
     that allow the assessment of--
       ``(A) health outcomes, presence of impairment, and 
     functional status of patients;
       ``(B) the continuity and coordination of care and care 
     transitions for patients across providers and health care 
     settings, including end of life care;
       ``(C) patient experience and patient engagement;
       ``(D) the safety, effectiveness, and timeliness of care;
       ``(E) health disparities including those associated with 
     individual race, ethnicity, age, gender, place of residence 
     or language; and
       ``(F) the efficiency and resource use in the provision of 
     care.
       ``(2) Use of funds.--An entity that enters into an 
     agreement under subsection (a) shall develop quality measures 
     that--
       ``(A) to the extent feasible, have the ability to be 
     collected through the use of health information technologies 
     supporting better delivery of health care services; and
       ``(B) are available free of charge to users for the use of 
     such measures.
       ``(3) Availability of measures.--The Secretary shall make 
     quality measures developed under this section available to 
     the public.
       ``(4) Testing of proposed measures.--The Secretary may use 
     amounts made available under subsection (f) to fund the 
     testing of proposed quality measures by qualified entities. 
     Testing funded under this paragraph shall include testing of 
     the feasibility and usability of proposed measures.
       ``(5) Updating of endorsed measures.--The Secretary may use 
     amounts made available under subsection (f) to fund the 
     updating (and testing, if applicable) by consensus-based 
     entities of quality measures that have been previously 
     endorsed by such an entity as new evidence is developed, in a 
     manner consistent with section 1890(b)(3).
       ``(d) Qualified Entities.--Before entering into agreements 
     with a qualified entity, the Secretary shall ensure that the 
     entity is a public, private, or academic institution with 
     technical expertise in the area of health quality 
     measurement.
       ``(e) Application for Grant.--A grant may be made under 
     this section only if an application for the grant is 
     submitted to the Secretary and the application is in such 
     form, is made in such manner, and contains such agreements, 
     assurances, and information as the Secretary determines to be 
     necessary to carry out this section.
       ``(f) Funding.--

[[Page 27310]]

       ``(1) In general.--The Secretary shall provide for the 
     transfer, from the Federal Hospital Insurance Trust Fund 
     under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841 (in such proportion 
     as the Secretary determines appropriate), of $25,000,000, to 
     the Secretary for purposes of carrying out this section for 
     each of the fiscal years 2010 through 2014.
       ``(2) Authorization of appropriations.--For purposes of 
     carrying out the provisions of this section, in addition to 
     funds otherwise available, out of any funds in the Treasury 
     not otherwise appropriated, there are appropriated to the 
     Secretary of Health and Human Services $25,000,000 for each 
     of the fiscal years 2010 through 2014.

     ``SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR 
                   QUALITY MEASUREMENT.

       ``(a) GAO Evaluations.--The Comptroller General of the 
     United States shall conduct periodic evaluations of the 
     implementation of the data collection processes for quality 
     measures used by the Secretary.
       ``(b) Considerations.--In carrying out the evaluation under 
     subsection (a), the Comptroller General shall determine--
       ``(1) whether the system for the collection of data for 
     quality measures provides for validation of data as relevant 
     and scientifically credible;
       ``(2) whether data collection efforts under the system use 
     the most efficient and cost-effective means in a manner that 
     minimizes administrative burden on persons required to 
     collect data and that adequately protects the privacy of 
     patients' personal health information and provides data 
     security;
       ``(3) whether standards under the system provide for an 
     appropriate opportunity for physicians and other clinicians 
     and institutional providers of services to review and correct 
     findings; and
       ``(4) the extent to which quality measures are consistent 
     with section 1192(c)(1) or result in direct or indirect costs 
     to users of such measures.
       ``(c) Report.--The Comptroller General shall submit reports 
     to Congress and to the Secretary containing a description of 
     the findings and conclusions of the results of each such 
     evaluation.''.

     SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT INTO 
                   SELECTION OF QUALITY MEASURES.

       Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) 
     is amended by adding at the end the following new subsection:
       ``(d) Multi-stakeholder Pre-rulemaking Input Into Selection 
     of Quality Measures.--
       ``(1) List of measures.--Not later than December 1 before 
     each year (beginning with 2011), the Secretary shall make 
     public a list of measures being considered for selection for 
     quality measurement by the Secretary in rulemaking with 
     respect to payment systems under this title beginning in the 
     payment year beginning in such year and for payment systems 
     beginning in the calendar year following such year, as the 
     case may be.
       ``(2) Consultation on selection of endorsed quality 
     measures.--A consensus-based entity that has entered into a 
     contract under section 1890 shall, as part of such contract, 
     convene multi-stakeholder groups to provide recommendations 
     on the selection of individual or composite quality measures, 
     for use in reporting performance information to the public or 
     for use in public health care programs.
       ``(3) Multi-stakeholder input.--Not later than February 1 
     of each year (beginning with 2011), the consensus-based 
     entity described in paragraph (2) shall transmit to the 
     Secretary the recommendations of multi-stakeholder groups 
     provided under paragraph (2). Such recommendations shall be 
     included in the transmissions the consensus-based entity 
     makes to the Secretary under the contract provided for under 
     section 1890.
       ``(4) Requirement for transparency in process.--
       ``(A) In general.--In convening multi-stakeholder groups 
     under paragraph (2) with respect to the selection of quality 
     measures, the consensus-based entity described in such 
     paragraph shall provide for an open and transparent process 
     for the activities conducted pursuant to such convening.
       ``(B) Selection of organizations participating in multi-
     stakeholder groups.--The process under paragraph (2) shall 
     ensure that the selection of representatives of multi-
     stakeholder groups includes provision for public nominations 
     for, and the opportunity for public comment on, such 
     selection.
       ``(5) Use of input.--The respective proposed rule shall 
     contain a summary of the recommendations made by the multi-
     stakeholder groups under paragraph (2), as well as other 
     comments received regarding the proposed measures, and the 
     extent to which such proposed rule follows such 
     recommendations and the rationale for not following such 
     recommendations.
       ``(6) Multi-stakeholder groups.--For purposes of this 
     subsection, the term `multi-stakeholder groups' means, with 
     respect to a quality measure, a voluntary collaborative of 
     organizations representing persons interested in or affected 
     by the use of such quality measure, such as the following:
       ``(A) Hospitals and other institutional providers.
       ``(B) Physicians.
       ``(C) Health care quality alliances.
       ``(D) Nurses and other health care practitioners.
       ``(E) Health plans.
       ``(F) Patient advocates and consumer groups.
       ``(G) Employers.
       ``(H) Public and private purchasers of health care items 
     and services.
       ``(I) Labor organizations.
       ``(J) Relevant departments or agencies of the United 
     States.
       ``(K) Biopharmaceutical companies and manufacturers of 
     medical devices.
       ``(L) Licensing, credentialing, and accrediting bodies.
       ``(7) Funding.--
       ``(A) In general.--The Secretary shall provide for the 
     transfer, from the Federal Hospital Insurance Trust Fund 
     under section 1817 and the Federal Supplementary Medical 
     Insurance Trust Fund under section 1841 (in such proportion 
     as the Secretary determines appropriate), of $1,000,000, to 
     the Secretary for purposes of carrying out this subsection 
     for each of the fiscal years 2010 through 2014.
       ``(B) Authorization of appropriations.--For purposes of 
     carrying out the provisions of this subsection, in addition 
     to funds otherwise available, out of any funds in the 
     Treasury not otherwise appropriated, there are appropriated 
     to the Secretary of Health and Human Services $1,000,000 for 
     each of the fiscal years 2010 through 2014.''.

     SEC. 1444. APPLICATION OF QUALITY MEASURES.

       (a) Inpatient Hospital Services.--Section 1886(b)(3)(B) of 
     such Act (42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at 
     the end the following new clause:
       ``(x)(I) Subject to subclause (II), for purposes of 
     reporting data on quality measures for inpatient hospital 
     services furnished during fiscal year 2012 and each 
     subsequent fiscal year, the quality measures specified under 
     clause (viii) shall be measures selected by the Secretary 
     from measures that have been endorsed by the entity with a 
     contract with the Secretary under section 1890(a).
       ``(II) In the case of a specified area or medical topic 
     determined appropriate by the Secretary for which a feasible 
     and practical quality measure has not been endorsed by the 
     entity with a contract under section 1890(a), the Secretary 
     may specify a measure that is not so endorsed as long as due 
     consideration is given to measures that have been endorsed or 
     adopted by a consensus organization identified by the 
     Secretary. The Secretary shall submit such a non-endorsed 
     measure to the entity for consideration for endorsement. If 
     the entity considers but does not endorse such a measure and 
     if the Secretary does not phase-out use of such measure, the 
     Secretary shall include the rationale for continued use of 
     such a measure in rulemaking.''.
       (b) Outpatient Hospital Services.--Section 1833(t)(17) of 
     such Act (42 U.S.C. 1395l(t)(17)) is amended by adding at the 
     end the following new subparagraph:
       ``(F) Use of endorsed quality measures.--The provisions of 
     clause (x) of section 1886(b)(3)(C) shall apply to quality 
     measures for covered OPD services under this paragraph in the 
     same manner as such provisions apply to quality measures for 
     inpatient hospital services.''.
       (c) Physicians' Services.--Section 1848(k)(2)(C)(ii) of 
     such Act (42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by 
     adding at the end the following: ``The Secretary shall submit 
     such a non-endorsed measure to the entity for consideration 
     for endorsement. If the entity considers but does not endorse 
     such a measure and if the Secretary does not phase-out use of 
     such measure, the Secretary shall include the rationale for 
     continued use of such a measure in rulemaking.''.
       (d) Renal Dialysis Services.--Section 1881(h)(2)(B)(ii) of 
     such Act (42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding 
     at the end the following: ``The Secretary shall submit such a 
     non-endorsed measure to the entity for consideration for 
     endorsement. If the entity considers but does not endorse 
     such a measure and if the Secretary does not phase-out use of 
     such measure, the Secretary shall include the rationale for 
     continued use of such a measure in rulemaking.''.
       (e) Endorsement of Standards.--Section 1890(b)(2) of the 
     Social Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by 
     adding after and below subparagraph (B) the following:
     ``If the entity does not endorse a measure, such entity shall 
     explain the reasons and provide suggestions about changes to 
     such measure that might make it a potentially endorsable 
     measure.''.
       (f) Effective Date.--Except as otherwise provided, the 
     amendments made by this section shall apply to quality 
     measures applied for payment years beginning with 2012 or 
     fiscal year 2012, as the case may be.

     SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.

       Section 1890(d) of the Social Security Act (42 U.S.C. 
     1395aaa(d)) is amended by striking ``for each of fiscal years 
     2009 through 2012'' and inserting ``for fiscal year 2009, and 
     $12,000,000 for each of the fiscal years 2010 through 2012''.

     SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE WITH 
                   ALZHEIMER'S DISEASE.

       (a) Quality Indicators.--The Secretary of Health and Human 
     Services shall develop

[[Page 27311]]

     quality indicators for the provision of medical services to 
     people with Alzheimer's disease and other dementias and a 
     plan for implementing the indicators to measure the quality 
     of care provided for people with these conditions by 
     physicians, hospitals, and other appropriate providers of 
     services and suppliers.
       (b) Report.--The Secretary shall submit a report to the 
     Committees on Energy and Commerce and Ways and Means of the 
     United States House of Representatives and to the Committees 
     on Finance and Health, Education, Labor, and Pensions of the 
     United States Senate not later than 24 months after the date 
     of the enactment of this Act setting forth the status of 
     their efforts to implement the requirements of subsection 
     (a).

           Subtitle D--Physician Payments Sunshine Provision

     SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN 
                   MANUFACTURERS AND DISTRIBUTORS OF COVERED 
                   DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 
                   SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND 
                   PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND 
                   BETWEEN PHYSICIANS AND OTHER HEALTH CARE 
                   ENTITIES.

       (a) In General.--Part A of title XI of the Social Security 
     Act (42 U.S.C. 1301 et seq.), as amended by section 1631(a), 
     is further amended by inserting after section 1128G the 
     following new section:

     ``SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS' FINANCIAL 
                   RELATIONSHIPS WITH MANUFACTURERS AND 
                   DISTRIBUTORS OF COVERED DRUGS, DEVICES, 
                   BIOLOGICALS, OR MEDICAL SUPPLIES UNDER 
                   MEDICARE, MEDICAID, OR CHIP AND WITH ENTITIES 
                   THAT BILL FOR SERVICES UNDER MEDICARE.

       ``(a) Reporting of Payments or Other Transfers of Value.--
       ``(1) In general.--Except as provided in this subsection, 
     not later than March 31, 2011, and annually thereafter, each 
     applicable manufacturer or distributor that provides a 
     payment or other transfer of value to a covered recipient, or 
     to an entity or individual at the request of or designated on 
     behalf of a covered recipient, shall submit to the Secretary, 
     in such electronic form as the Secretary shall require, the 
     following information with respect to the preceding calendar 
     year:
       ``(A) With respect to the covered recipient, the 
     recipient's name, business address, physician specialty, and 
     national provider identifier.
       ``(B) With respect to the payment or other transfer of 
     value, other than a drug sample--
       ``(i) its value and date;
       ``(ii) the name of the related drug, device, or supply, if 
     available, to the level of specificity available; and
       ``(iii) a description of its form, indicated (as 
     appropriate for all that apply) as--

       ``(I) cash or a cash equivalent;
       ``(II) in-kind items or services;
       ``(III) stock, a stock option, or any other ownership 
     interest, dividend, profit, or other return on investment; or
       ``(IV) any other form (as defined by the Secretary).

       ``(C) With respect to a drug sample, the name, number, 
     date, and dosage units of the sample.
       ``(2) Aggregate reporting.--Information submitted by an 
     applicable manufacturer or distributor under paragraph (1) 
     shall include the aggregate amount of all payments or other 
     transfers of value provided by the manufacturer or 
     distributor to covered recipients (and to entities or 
     individuals at the request of or designated on behalf of a 
     covered recipient) during the year involved, including all 
     payments and transfers of value regardless of whether such 
     payments or transfer of value were individually disclosed.
       ``(3) Special rule for certain payments or other transfers 
     of value.--In the case where an applicable manufacturer or 
     distributor provides a payment or other transfer of value to 
     an entity or individual at the request of or designated on 
     behalf of a covered recipient, the manufacturer or 
     distributor shall disclose that payment or other transfer of 
     value under the name of the covered recipient.
       ``(4) Delayed reporting for payments made pursuant to 
     product development agreements.--In the case of a payment or 
     other transfer of value made to a covered recipient by an 
     applicable manufacturer or distributor pursuant to a product 
     development agreement for services furnished in connection 
     with the development of a new drug, device, biological, or 
     medical supply, the applicable manufacturer or distributor 
     may report the value and recipient of such payment or other 
     transfer of value in the first reporting period under this 
     subsection in the next reporting deadline after the earlier 
     of the following:
       ``(A) The date of the approval or clearance of the covered 
     drug, device, biological, or medical supply by the Food and 
     Drug Administration.
       ``(B) Two calendar years after the date such payment or 
     other transfer of value was made.
       ``(5) Delayed reporting for payments made pursuant to 
     clinical investigations.--In the case of a payment or other 
     transfer of value made to a covered recipient by an 
     applicable manufacturer or distributor in connection with a 
     clinical investigation regarding a new drug, device, 
     biological, or medical supply, the applicable manufacturer or 
     distributor may report as required under this section in the 
     next reporting period under this subsection after the earlier 
     of the following:
       ``(A) The date that the clinical investigation is 
     registered on the website maintained by the National 
     Institutes of Health pursuant to section 671 of the Food and 
     Drug Administration Amendments Act of 2007.
       ``(B) Two calendar years after the date such payment or 
     other transfer of value was made.
       ``(6) Confidentiality.--Information described in paragraph 
     (4) or (5) shall be considered confidential and shall not be 
     subject to disclosure under section 552 of title 5, United 
     States Code, or any other similar Federal, State, or local 
     law, until or after the date on which the information is made 
     available to the public under such paragraph.
       ``(7) Physicians in self-insured health plans.--Nothing in 
     this subsection shall be construed to require the disclosure 
     of a payment or other transfer of value to a physician by a 
     self-insured health plan.
       ``(b) Reporting of Ownership Interest by Physicians.--
       ``(1) Hospitals and other entities that bill medicare.--Not 
     later than March 31 of each year (beginning with 2011), each 
     hospital or other health care entity (not including a 
     Medicare Advantage organization) that bills the Secretary 
     under part A or part B of title XVIII for services shall 
     report on the ownership shares (other than ownership shares 
     described in section 1877(c)) of each physician who, directly 
     or indirectly, owns an interest in the entity.
       ``(2) Additional physician ownership.--Not later than March 
     31 of each year (beginning with 2011), in addition to the 
     requirement under subsection (a)(1), any applicable 
     manufacturer, applicable group purchasing organization, or 
     applicable distributor shall submit to the Secretary, in such 
     electronic form as the Secretary shall require, the following 
     information regarding any ownership or investment interest 
     (other than an ownership or investment interest in a publicly 
     traded security and mutual fund, as described in section 
     1877(c)) held by a physician (or an immediate family member 
     of such physician (as defined for purposes of section 
     1877(a))) in the applicable manufacturer, applicable group 
     purchasing organization or applicable distributor during the 
     preceding year:
       ``(A) The dollar amount invested by each physician holding 
     such an ownership or investment interest.
       ``(B) The value and terms of each such ownership or 
     investment interest.
       ``(C) Any payment or other transfer of value provided to a 
     physician holding such an ownership or investment interest 
     (or to an entity or individual at the request of or 
     designated on behalf of a physician holding such an ownership 
     or investment interest), including the information described 
     in clauses (i) through (iii) of paragraph (a)(1)(B), and 
     information described in subsection (f)(8)(A) and (f)(8)(B).
       ``(D) Any other information regarding the ownership or 
     investment interest the Secretary determines appropriate.
       ``(3) Definitions.--In this subsection:
       ``(A) Physician.--The term `physician' includes a 
     physician's immediate family members (as defined for purposes 
     of section 1877(a)).
       ``(B) Applicable group purchasing organization.--The term 
     `applicable group purchasing organization' means any 
     organization or other entity (as defined by the Secretary) 
     that purchases, arranges for, or negotiates the purchase of a 
     covered drug, device, biological, or medical supply.
       ``(4) Study of practice patterns in advanced diagnostic 
     imaging and radiation oncology services.--The Comptroller 
     General of the United States shall conduct a study to 
     evaluate the extent of use of physician self-referral 
     arrangements and the effects of such arrangements on the cost 
     of providing advanced diagnostic imaging and radiation 
     oncology services to Medicare beneficiaries under title 
     XVIII. The study shall be completed and submitted to Congress 
     not later than July 1, 2011.
       ``(c) Public Availability.--
       ``(1) In general.--The Secretary shall establish procedures 
     to ensure that, not later than September 30, 2011, and on 
     June 30 of each year beginning thereafter, the information 
     submitted under subsections (a) and (b), other than 
     information regard drug samples, with respect to the 
     preceding calendar year is made available through an Internet 
     website that--
       ``(A) is searchable and is in a format that is clear and 
     understandable;
       ``(B) contains information that is presented by the name of 
     the applicable manufacturer or distributor, the name of the 
     covered recipient, the business address of the covered 
     recipient, the specialty (if applicable) of the covered 
     recipient, the value of the payment or other transfer of 
     value, the date on which the payment or other transfer of 
     value was provided to the covered recipient, the form of the 
     payment or other transfer of

[[Page 27312]]

     value, indicated (as appropriate) under subsection 
     (a)(1)(B)(ii), the nature of the payment or other transfer of 
     value, indicated (as appropriate) under subsection 
     (a)(1)(B)(iii), and the name of the covered drug, device, 
     biological, or medical supply, as applicable;
       ``(C) contains information that is able to be easily 
     aggregated and downloaded;
       ``(D) contains a description of any enforcement actions 
     taken to carry out this section, including any penalties 
     imposed under subsection (d), during the preceding year;
       ``(E) contains background information on industry-physician 
     relationships;
       ``(F) in the case of information submitted with respect to 
     a payment or other transfer of value described in subsection 
     (a)(5), lists such information separately from the other 
     information submitted under subsection (a) and designates 
     such separately listed information as funding for clinical 
     research;
       ``(G) contains any other information the Secretary 
     determines would be helpful to the average consumer; and
       ``(H) provides the covered recipient an opportunity to 
     submit corrections to the information made available to the 
     public with respect to the covered recipient.
       ``(2) Accuracy of reporting.--The accuracy of the 
     information that is submitted under subsections (a) and (b) 
     and made available under paragraph (1) shall be the 
     responsibility of the reporting entity reporting under 
     subsection (a) or (b), as applicable. The Secretary shall 
     establish procedures to ensure that the covered recipient is 
     provided with an opportunity to submit corrections to the 
     applicable reporting entity with regard to information made 
     public with respect to the covered recipient and, under such 
     procedures, the corrections shall be transmitted to the 
     Secretary.
       ``(3) Special rule for drug samples.--Information relating 
     to drug samples provided under subsection (a) shall not be 
     made available to the public by the Secretary but may be made 
     available outside the Department of Health and Human Services 
     by the Secretary for research or legitimate business purposes 
     pursuant to data use agreements.
       ``(4) Special rule for national provider identifiers.--
     Information relating to national provider identifiers 
     provided under subsection (a) shall not be made available to 
     the public by the Secretary but may be made available outside 
     the Department of Health and Human Services by the Secretary 
     for research or legitimate business purposes pursuant to data 
     use agreements.
       ``(d) Penalties for Noncompliance.--
       ``(1) Failure to report.--
       ``(A) In general.--Subject to subparagraph (B), except as 
     provided in paragraph (2), any reporting entity that fails to 
     submit information required under subsection (a) or (b), as 
     applicable, in a timely manner in accordance with regulations 
     promulgated to carry out such applicable subsection shall be 
     subject to a civil money penalty of not less than $1,000, but 
     not more than $10,000, for each payment or other transfer of 
     value or ownership or investment interest not reported as 
     required under such subsection. Such penalty shall be imposed 
     and collected in the same manner as civil money penalties 
     under subsection (a) of section 1128A are imposed and 
     collected under that section.
       ``(B) Limitation.--The total amount of civil money 
     penalties imposed under subparagraph (A), with respect to 
     each annual submission of information under subsection (a) by 
     a reporting entity, shall not exceed $150,000.
       ``(2) Knowing failure to report.--
       ``(A) In general.--Subject to subparagraph (B), any 
     reporting entity that knowingly fails to submit information 
     required under subsection (a) or (b), as applicable, in a 
     timely manner in accordance with regulations promulgated to 
     carry out such applicable subsection, shall be subject to a 
     civil money penalty of not less than $10,000, but not more 
     than $100,000, for each payment or other transfer of value or 
     ownership or investment interest not reported as required 
     under such subsection. Such penalty shall be imposed and 
     collected in the same manner as civil money penalties under 
     subsection (a) of section 1128A are imposed and collected 
     under that section.
       ``(B) Limitation.--The total amount of civil money 
     penalties imposed under subparagraph (A) with respect to each 
     annual submission of information under subsection (a) or (b) 
     by an applicable reporting entity shall not exceed 
     $1,000,000, or, if greater, 0.1 percentage of the total 
     annual revenues of the reporting entity.
       ``(3) Use of funds.--Funds collected by the Secretary as a 
     result of the imposition of a civil money penalty under this 
     subsection shall be used to carry out this section.
       ``(4) Enforcement through state attorneys general.--The 
     attorney general of a State, after providing notice to the 
     Secretary of an intent to proceed under this paragraph in a 
     specific case and providing the Secretary with an opportunity 
     to bring an action under this subsection and the Secretary 
     declining such opportunity, may proceed under this subsection 
     against an applicable manufacturer or distributor in the 
     State.
       ``(e) Annual Report to Congress.--Not later than April 1 of 
     each year beginning with 2011, the Secretary shall submit to 
     Congress a report that includes the following:
       ``(1) The information submitted under this section during 
     the preceding year, aggregated for each applicable reporting 
     entity that submitted such information during such year.
       ``(2) A description of any enforcement actions taken to 
     carry out this section, including any penalties imposed under 
     subsection (d), during the preceding year.
       ``(f) Definitions.--In this section:
       ``(1) Applicable distributor.--The term `applicable 
     distributor' means--
       ``(A) any entity, other than an applicable group purchasing 
     organization, that buys and resells, or receives a commission 
     or other similar form of payment, from another seller, for 
     selling or arranging for the sale of a covered drug, device, 
     biological, or medical supply; or
       ``(B) any entity under common ownership with such an entity 
     described in subparagraph (A) and which provides assistance 
     or support to such entity so described with respect to the 
     production, preparation, propagation, compounding, 
     conversion, processing, marketing, or distribution of a 
     covered drug, device, biological, or medical supply.

     Such term does not include a wholesale pharmaceutical 
     distributor.
       ``(2) Applicable manufacturer.--The term `applicable 
     manufacturer' means any entity which is engaged in the 
     production, preparation, propagation, compounding, 
     conversion, processing, marketing, or manufacturer-direct 
     distribution of a covered drug, device, biological, or 
     medical supply (or any entity under common ownership with 
     such entity and which provides assistance or support to such 
     entity with respect to the production, preparation, 
     propagation, compounding, conversion, processing, marketing, 
     or distribution or a covered drug, device, biological, or 
     medical supply). For purposes of this section only, such term 
     does not include a retail pharmacy licensed under State law.
       ``(3) Clinical investigation.--The term `clinical 
     investigation' means any experiment involving one or more 
     human subjects, or materials derived from human subjects, in 
     which a drug or device is administered, dispensed, or used.
       ``(4) Covered drug, device, biological, or medical 
     supply.--The term `covered' means, with respect to a drug, 
     device, biological, or medical supply, such a drug, device, 
     biological, or medical supply for which payment is available 
     under title XVIII or a State plan under title XIX or XXI (or 
     a waiver of such a plan).
       ``(5) Covered recipient.--The term `covered recipient' 
     means the following:
       ``(A) A physician.
       ``(B) A physician group practice.
       ``(C) Any other prescriber of a covered drug, device, 
     biological, or medical supply.
       ``(D) A pharmacy or pharmacist.
       ``(E) A health insurance issuer, group health plan, or 
     other entity offering a health benefits plan, including any 
     employee of such an issuer, plan, or entity.
       ``(F) A pharmacy benefit manager, including any employee of 
     such a manager.
       ``(G) A hospital.
       ``(H) A medical school.
       ``(I) A sponsor of a continuing medical education program.
       ``(J) A patient advocacy or disease specific group.
       ``(K) A organization of health care professionals.
       ``(L) A biomedical researcher.
       ``(M) A group purchasing organization.
       ``(6) Employee.--The term `employee' has the meaning given 
     such term in section 1877(h)(2).
       ``(7) Knowingly.--The term `knowingly' has the meaning 
     given such term in section 3729(b) of title 31, United States 
     Code.
       ``(8) Payment or other transfer of value.--
       ``(A) In general.--The term `payment or other transfer of 
     value' means a transfer of anything of value for or of any of 
     the following:
       ``(i) Gift, food, or entertainment.
       ``(ii) Travel or trip.
       ``(iii) Honoraria.
       ``(iv) Research funding or grant.
       ``(v) Education or conference funding.
       ``(vi) Consulting fees.
       ``(vii) Ownership or investment interest and royalties or 
     license fee.
       ``(B) Inclusions.--Subject to subparagraph (C), the term 
     `payment or other transfer of value' includes any 
     compensation, gift, honorarium, speaking fee, consulting fee, 
     travel, services, dividend, profit distribution, stock or 
     stock option grant, or any ownership or investment interest 
     held by a physician in a manufacturer (excluding a dividend 
     or other profit distribution from, or ownership or investment 
     interest in, a publicly traded security or mutual fund (as 
     described in section 1877(c))).
       ``(C) Exclusions.--The term `payment or other transfer of 
     value' does not include the following:
       ``(i) Any payment or other transfer of value provided by an 
     applicable manufacturer or distributor to a covered recipient 
     where the amount transferred to, requested by, or designated 
     on behalf of the covered recipient does not exceed $5.
       ``(ii) The loan of a covered device for a short-term trial 
     period, not to exceed 90

[[Page 27313]]

     days, to permit evaluation of the covered device by the 
     covered recipient.
       ``(iii) Items or services provided under a contractual 
     warranty, including the replacement of a covered device, 
     where the terms of the warranty are set forth in the purchase 
     or lease agreement for the covered device.
       ``(iv) A transfer of anything of value to a covered 
     recipient when the covered recipient is a patient and not 
     acting in the professional capacity of a covered recipient.
       ``(v) In-kind items used for the provision of charity care.
       ``(vi) A dividend or other profit distribution from, or 
     ownership or investment interest in, a publicly traded 
     security and mutual fund (as described in section 1877(c)).
       ``(vii) Compensation paid by an applicable manufacturer or 
     distributor to a covered recipient who is directly employed 
     by and works solely for such manufacturer or distributor.
       ``(viii) Payments made to a covered recipient by an 
     applicable manufacturer or by a health plan affiliated with 
     an applicable manufacturer for medical care provided to 
     employees of such manufacturer or their dependents.
       ``(ix) Any discount (including a rebate).
       ``(x) Any payment or other transfer of value that is made 
     to a covered recipient indirectly through an entity other 
     than the applicable manufacturer in connection with an 
     activity or service--

       ``(I) in which the applicable manufacturer is unaware of 
     the identity of the covered recipient and is not using such 
     activity or service to market its product to the covered 
     recipient; and
       ``(II) that is not designed to market or promote the 
     product to the covered recipient.

       ``(xi) In the case of an applicable manufacturer who offers 
     a self-insured plan, payments for the provision of health 
     care to employees under the plan.
       ``(9) Physician.--The term `physician' has the meaning 
     given that term in section 1861(r). For purposes of this 
     section, such term does not include a physician who is an 
     employee of the applicable manufacturer that is required to 
     submit information under subsection (a).
       ``(10) Reporting entity.--The term `reporting entity' 
     means--
       ``(A) with respect to the reporting requirement under 
     subsection (a), an applicable manufacturer or distributor of 
     a covered drug, device, biological, or medical supply 
     required to report under such subsection; and
       ``(B) with respect to the reporting requirement under 
     subsection (b), a hospital, other health care entity, 
     applicable manufacturer, applicable distributor, or 
     applicable group purchasing organization required to report 
     physician ownership under such subsection.
       ``(g) Annual Reports to States.--Not later than April 1 of 
     each year beginning with 2011, the Secretary shall submit to 
     States a report that includes a summary of the information 
     submitted under subsections (a), (b), and (e) during the 
     preceding year with respect to covered recipients or other 
     hospitals and entities in the State.
       ``(h) Relation to State Laws.--
       ``(1) In general.--Effective on January 1, 2011, subject to 
     paragraph (2), the provisions of this section shall preempt 
     any law or regulation of a State or of a political 
     subdivision of a State that requires an applicable 
     manufacturer and applicable distributor (as such terms are 
     defined in subsection (f)) to disclose or report, in any 
     format, the type of information (described in subsection (a)) 
     regarding a payment or other transfer of value provided by 
     the manufacturer to a covered recipient (as so defined).
       ``(2) No preemption of additional requirements.--Paragraph 
     (1) shall not preempt any statute or regulation of a State or 
     political subdivision of a State that requires any of the 
     following:
       ``(A) The disclosure or reporting of information not of the 
     type required to be disclosed or reported under this section.
       ``(B) The disclosure or reporting, in any format, of 
     information described in subsection (f)(8)(C), except in the 
     case of information described in clause (i) of subsection 
     (f)(8)(C).
       ``(C) The disclosure or reporting, in any format, of the 
     type of information by any person or entity other than an 
     applicable manufacturer (as so defined) or a covered 
     recipient (as defined in subsection (f)).
       ``(D) The disclosure or reporting, in any format, of the 
     type of information required to be disclosed or reported 
     under this section to a Federal, State, or local governmental 
     agency for public health surveillance, investigation, or 
     other public health purposes or health oversight purposes.

     Nothing in paragraph (1) shall be construed to limit the 
     discovery or admissibility of information described in this 
     paragraph in a criminal, civil, or administrative 
     proceeding.''.
       (b) Availability of Information From the Disclosure of 
     Financial Relationship Report (DFRR).--The Secretary of 
     Health and Human Services shall submit to Congress a report 
     on the full results of the Disclosure of Physician Financial 
     Relationships surveys required pursuant to section 5006 of 
     the Deficit Reduction Act of 2005. Such report shall be 
     submitted to Congress not later than the date that is 6 
     months after the date such surveys are collected and shall be 
     made publicly available on an Internet website of the 
     Department of Health and Human Services.
       (c) GAO Report.--Not later than December 31, 2012, the 
     Comptroller General of the United States shall submit to 
     Congress a report on section 1128H of the Social Security 
     Act, as added by subsection (a). Such report shall address 
     the extent to which important transfers of value are being 
     adequately reported under such section (including unreported 
     transfers required by such section as well as transfers not 
     required to be reported by such section), the impact on 
     States of the federal preemption provision under subsection 
     (h) of such section, whether changes have occurred in the 
     pattern of payments as a result of efforts to evade reporting 
     requirements, a description of the financial relationships 
     subject to delayed reporting under subsection (a) of such 
     section, and any recommended improvements to the collection 
     or the analysis of data reported under such section.

   Subtitle E--Public Reporting on Health Care-Associated Infections

     SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND 
                   AMBULATORY SURGICAL CENTERS ON HEALTH CARE-
                   ASSOCIATED INFECTIONS.

       (a) In General.--Title XI of the Social Security Act is 
     amended by inserting after section 1138 the following 
     section:

     ``SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS 
                   AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-
                   ASSOCIATED INFECTIONS.

       ``(a) Reporting Requirement.--
       ``(1) In general.--The Secretary shall provide that a 
     hospital (as defined in subsection (g)) or ambulatory 
     surgical center meeting the requirements of titles XVIII or 
     XIX may participate in the programs established under such 
     titles only if, in accordance with this section, the hospital 
     or center reports such information on health care-associated 
     infections that develop in the hospital or center (and such 
     demographic information associated with such infections) as 
     the Secretary specifies.
       ``(2) Reporting protocols.-- Such information shall be 
     reported in accordance with reporting protocols established 
     by the Secretary through the Director of the Centers for 
     Disease Control and Prevention (in this section referred to 
     as the `CDC') and to the National Healthcare Safety Network 
     of the CDC or under such another reporting system of such 
     Centers as determined appropriate by the Secretary in 
     consultation with such Director.
       ``(3) Coordination with hit.--The Secretary, through the 
     Director of the CDC and the Office of the National 
     Coordinator for Health Information Technology, shall ensure 
     that the transmission of information under this subsection is 
     coordinated with systems established under the HITECH Act, 
     where appropriate.
       ``(4) Procedures to ensure the validity of information.--
     The Secretary shall establish procedures regarding the 
     validity of the information submitted under this subsection 
     in order to ensure that such information is appropriately 
     compared across hospitals and centers. Such procedures shall 
     address failures to report as well as errors in reporting.
       ``(5) Implementation.--Not later than 1 year after the date 
     of enactment of this section, the Secretary, through the 
     Director of CDC, shall promulgate regulations to carry out 
     this section.
       ``(b) Public Posting of Information.--The Secretary shall 
     promptly post, on the official public Internet site of the 
     Department of Health and Human Services, the information 
     reported under subsection (a). Such information shall be set 
     forth in a manner that allows for the comparison of 
     information on health care-associated infections--
       ``(1) among hospitals and ambulatory surgical centers; and
       ``(2) by demographic information.
       ``(c) Annual Report to Congress.--On an annual basis the 
     Secretary shall submit to the Congress a report that 
     summarizes each of the following:
       ``(1) The number and types of health care-associated 
     infections reported under subsection (a) in hospitals and 
     ambulatory surgical centers during such year.
       ``(2) Factors that contribute to the occurrence of such 
     infections, including health care worker immunization rates.
       ``(3) Based on the most recent information available to the 
     Secretary on the composition of the professional staff of 
     hospitals and ambulatory surgical centers, the number of 
     certified infection control professionals on the staff of 
     hospitals and ambulatory surgical centers.
       ``(4) The total increases or decreases in health care costs 
     that resulted from increases or decreases in the rates of 
     occurrence of each such type of infection during such year.
       ``(5) Recommendations, in coordination with the Center for 
     Quality Improvement established under section 931 of the 
     Public Health Service Act, for best practices to eliminate 
     the rates of occurrence of each such type of infection in 
     hospitals and ambulatory surgical centers.
       ``(d) Non-preemption of State Laws.--Nothing in this 
     section shall be construed as

[[Page 27314]]

     preempting or otherwise affecting any provision of State law 
     relating to the disclosure of information on health care-
     associated infections or patient safety procedures for a 
     hospital or ambulatory surgical center.
       ``(e) Health Care-associated Infection.--For purposes of 
     this section:
       ``(1) In general.--The term `health care-associated 
     infection' means an infection that develops in a patient who 
     has received care in any institutional setting where health 
     care is delivered and is related to receiving health care.
       ``(2) Related to receiving health care.--The term `related 
     to receiving health care', with respect to an infection, 
     means that the infection was not incubating or present at the 
     time health care was provided.
       ``(f) Application to Critical Access Hospitals.--For 
     purposes of this section, the term `hospital' includes a 
     critical access hospital, as defined in section 
     1861(mm)(1).''.
       (b) Effective Date.--With respect to section 1138A of the 
     Social Security Act (as inserted by subsection (a) of this 
     section), the requirement under such section that hospitals 
     and ambulatory surgical centers submit reports takes effect 
     on such date (not later than 2 years after the date of the 
     enactment of this Act) as the Secretary of Health and Human 
     Services shall specify. In order to meet such deadline, the 
     Secretary may implement such section through guidance or 
     other instructions.
       (c) GAO Report.--Not later than 18 months after the date of 
     the enactment of this Act, the Comptroller General of the 
     United States shall submit to Congress a report on the 
     program established under section 1138A of the Social 
     Security Act, as inserted by subsection (a). Such report 
     shall include an analysis of the appropriateness of the types 
     of information required for submission, compliance with 
     reporting requirements, the success of the validity 
     procedures established, and any conflict or overlap between 
     the reporting required under such section and any other 
     reporting systems mandated by either the States or the 
     Federal Government.
       (d) Report on Additional Data.--Not later than 18 months 
     after the date of the enactment of this Act, the Secretary of 
     Health and Human Services shall submit to the Congress a 
     report on the appropriateness of expanding the requirements 
     under such section to include additional information (such as 
     health care worker immunization rates), in order to improve 
     health care quality and patient safety.

              TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

     SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS.

       (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 ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)'';
       (2) in paragraph (4)(H)(i), by striking ``paragraph (7)'' 
     and inserting ``paragraphs (7) and (8)'';
       (3) in paragraph (7)(E), by inserting ``and paragraph (8)'' 
     after ``this paragraph''; and
       (4) by adding at the end the following new paragraph:
       ``(8) Additional redistribution of unused residency 
     positions.--
       ``(A) Reductions in limit based on unused positions.--
       ``(i) Programs subject to reduction.--If a hospital's 
     reference resident level (specified in clause (ii)) is less 
     than the otherwise applicable resident limit (as defined in 
     subparagraph (C)(ii)), effective for portions of cost 
     reporting periods occurring on or after July 1, 2011, the 
     otherwise applicable resident limit shall be reduced by 90 
     percent of the difference between such otherwise applicable 
     resident limit and such reference resident level.
       ``(ii) Reference resident level.--

       ``(I) In general.--Except as otherwise provided in a 
     subsequent subclause, the reference resident level specified 
     in this clause for a hospital is the highest resident level 
     for any of the 3 most recent cost reporting periods (ending 
     before the date of the enactment of this paragraph) of the 
     hospital for which a cost report has been settled (or, if 
     not, submitted (subject to audit)), as determined by the 
     Secretary.
       ``(II) Use of most recent accounting period to recognize 
     expansion of existing programs.--If a hospital submits a 
     timely request to increase its resident level due to an 
     expansion, or planned expansion, of an existing residency 
     training program that is not reflected on the most recent 
     settled or submitted cost report, after audit and subject to 
     the discretion of the Secretary, subject to subclause (IV), 
     the reference resident level for such hospital is the 
     resident level that includes the additional residents 
     attributable to such expansion or establishment, as 
     determined by the Secretary. The Secretary is authorized to 
     determine an alternative reference resident level for a 
     hospital that submitted to the Secretary a timely request, 
     before the start of the 2009-2010 academic year, for an 
     increase in its reference resident level due to a planned 
     expansion.
       ``(III) Special provider agreement.--In the case of a 
     hospital described in paragraph (4)(H)(v), the reference 
     resident level specified in this clause is the limitation 
     applicable under subclause (I) of such paragraph.
       ``(IV) Previous redistribution.--The reference resident 
     level specified in this clause for a hospital shall be 
     increased to the extent required to take into account an 
     increase in resident positions made available to the hospital 
     under paragraph (7)(B) that are not otherwise taken into 
     account under a previous subclause.

       ``(iii) Affiliation.--The provisions of clause (i) shall be 
     applied to hospitals which are members of the same affiliated 
     group (as defined by the Secretary under paragraph 
     (4)(H)(ii)) and to the extent the hospitals can demonstrate 
     that they are filling any additional  resident slots 
     allocated to other hospitals through an affiliation 
     agreement, the Secretary shall adjust the determination of 
     available slots accordingly, or which the Secretary otherwise 
     has permitted the resident positions (under section 402 of 
     the Social Security Amendments of 1967) to be aggregated for 
     purposes of applying the resident position limitations under 
     this subsection.
       ``(B) Redistribution.--
       ``(i) In general.--The Secretary shall increase the 
     otherwise applicable resident limit for each qualifying 
     hospital that submits an application under this subparagraph 
     by such number as the Secretary may approve for portions of 
     cost reporting periods occurring on or after July 1, 2011. 
     The estimated aggregate number of increases in the otherwise 
     applicable resident limit under this subparagraph may not 
     exceed the Secretary's estimate of the aggregate reduction in 
     such limits attributable to subparagraph (A).
       ``(ii) Requirements for qualifying hospitals.--A hospital 
     is not a qualifying hospital for purposes of this paragraph 
     unless the following requirements are met:

       ``(I) Maintenance of primary care resident level.--The 
     hospital maintains the number of primary care residents at a 
     level that is not less than the base level of primary care 
     residents increased by the number of additional primary care 
     resident positions provided to the hospital under this 
     subparagraph. For purposes of this subparagraph, the `base 
     level of primary care residents' for a hospital is the level 
     of such residents as of a base period (specified by the 
     Secretary), determined without regard to whether such 
     positions were in excess of the otherwise applicable resident 
     limit for such period but taking into account the application 
     of subclauses (II) and (III) of subparagraph (A)(ii).
       ``(II) Dedicated assignment of additional resident 
     positions to primary care.--The hospital assigns all such 
     additional resident positions for primary care residents.
       ``(III) Accreditation.--The hospital's residency programs 
     in primary care are fully accredited or, in the case of a 
     residency training program not in operation as of the base 
     year, the hospital is actively applying for such 
     accreditation for the program for such additional resident 
     positions (as determined by the Secretary).

       ``(iii) Considerations in redistribution.--In determining 
     for which qualifying hospitals the increase in the otherwise 
     applicable resident limit is provided under this 
     subparagraph, the Secretary shall take into account the 
     demonstrated likelihood of the hospital filling the positions 
     within the first 3 cost reporting periods beginning on or 
     after July 1, 2011, made available under this subparagraph, 
     as determined by the Secretary.
       ``(iv) Priority for certain hospitals.--In determining for 
     which qualifying hospitals the increase in the otherwise 
     applicable resident limit is provided under this 
     subparagraph, the Secretary shall distribute the increase to 
     qualifying hospitals based on the following criteria:

       ``(I) The Secretary shall give preference to hospitals that 
     had a reduction in resident training positions under 
     subparagraph (A).
       ``(II) The Secretary shall give preference to hospitals 
     with 3-year primary care residency training programs, such as 
     family practice and general internal medicine.
       ``(III) The Secretary shall give preference to hospitals 
     insofar as they have in effect formal arrangements (as 
     determined by the Secretary) that place greater emphasis upon 
     training in Federally qualified health centers, rural health 
     clinics, and other nonprovider settings, and to hospitals 
     that receive additional payments under subsection (d)(5)(F) 
     and emphasize training in an outpatient department.
       ``(IV) The Secretary shall give preference to hospitals 
     with a number of positions (as of July 1, 2009) in excess of 
     the otherwise applicable resident limit for such period.
       ``(V) The Secretary shall give preference to hospitals that 
     place greater emphasis upon training in a health professional 
     shortage area (designated under section 332 of the Public 
     Health Service Act) or a health professional needs area 
     (designated under section 2211 of such Act).
       ``(VI) The Secretary shall give preference to hospitals in 
     States that have low resident-to-population ratios (including 
     a greater preference for those States with lower resident-to-
     population ratios).

       ``(v) Limitation.--In no case shall more than 20 full-time 
     equivalent additional residency positions be made available 
     under this subparagraph with respect to any hospital.

[[Page 27315]]

       ``(vi) Application of per resident amounts for primary 
     care.--With respect to additional residency positions in a 
     hospital attributable to the increase provided under this 
     subparagraph, the approved FTE 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.
       ``(vii) Distribution.--The Secretary shall distribute the 
     increase in resident training positions to qualifying 
     hospitals under this subparagraph not later than July 1, 
     2011.
       ``(C) Resident level and limit defined.--In this paragraph:
       ``(i) The term `resident level' has the meaning given such 
     term in paragraph (7)(C)(i).
       ``(ii) 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 paragraph 
     (7)(A).
       ``(D) Maintenance of primary care resident level.--In 
     carrying out this paragraph, the Secretary shall require 
     hospitals that receive additional resident positions under 
     subparagraph (B)--
       ``(i) to maintain records, and periodically report to the 
     Secretary, on the number of primary care residents in its 
     residency training programs; and
       ``(ii) as a condition of payment for a cost reporting 
     period under this subsection for such positions, to maintain 
     the level of such positions at not less than the sum of--

       ``(I) the base level of primary care resident positions (as 
     determined under subparagraph (B)(ii)(I)) before receiving 
     such additional positions; and
       ``(II) the number of such additional positions.''.

       (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--
       (A) by striking ``subsection (h)(7)'' and inserting 
     ``subsections (h)(7) and (h)(8)''; and
       (B) by striking ``it applies'' and inserting ``they 
     apply''.
       (2) Conforming provision.--Section 1886(d)(5)(B) of the 
     Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
     adding at the end the following clause:
       ``(x) For discharges occurring on or after July 1, 2011, 
     insofar as an additional payment amount under this 
     subparagraph is attributable to resident positions 
     distributed to a hospital under subsection (h)(8)(B), the 
     indirect teaching adjustment factor shall be computed in the 
     same manner as provided under clause (ii) with respect to 
     such resident positions.''.
       (c) Conforming Amendment.--Section 422(b)(2) of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (Public Law 108-173) is amended by striking 
     ``section 1886(h)(7)'' and all that follows and inserting 
     ``paragraphs (7) and (8) of subsection (h) of section 1886 of 
     the Social Security Act.''.

     SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.

       (a) Direct GME.--Section 1886(h)(4)(E) of the Social 
     Security Act (42 U.S.C. 1395ww(h)) is amended--
       (1) by designating the first sentence as a clause (i) with 
     the heading ``In general.--'' and appropriate indentation;
       (2) by striking ``shall be counted and that all the time'' 
     and inserting ``shall be counted and that--

       ``(I) effective for cost reporting periods beginning before 
     July 1, 2009, all the time'';

       (3) in subclause (I), as inserted by paragraph (1), by 
     striking the period at the end and inserting ``; and''; and
       (A) by inserting after subclause (I), as so inserted, the 
     following:

       ``(II) effective for cost reporting periods beginning on or 
     after July 1, 2009, all the time so spent by a resident shall 
     be counted towards the determination of full-time 
     equivalency, without regard to the setting in which the 
     activities are performed, if the hospital incurs the costs of 
     the stipends and fringe benefits of the resident during the 
     time the resident spends in that setting.

     Any hospital claiming under this subparagraph for time spent 
     in a nonprovider setting shall maintain and make available to 
     the Secretary records regarding the amount of such time and 
     such amount in comparison with amounts of such time in such 
     base year as the Secretary shall specify.''.
       (b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security 
     Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
       (1) by striking ``(iv) Effective for discharges occurring 
     on or after October 1, 1997'' and inserting ``(iv)(I) 
     Effective for discharges occurring on or after October 1, 
     1997, and before July 1, 2009''; and
       (2) by inserting after subclause (I), as inserted by 
     paragraph (1), the following new subclause:
       ``(II) Effective for discharges occurring on or after July 
     1, 2009, all the time spent by an intern or resident in 
     patient care activities at an entity in a nonprovider setting 
     shall be counted towards the determination of full-time 
     equivalency if the hospital incurs the costs of the stipends 
     and fringe benefits of the intern or resident during the time 
     the intern or resident spends in that setting.''.
       (c) OIG Study on Impact on Training.--The Inspector General 
     of the Department of Health and Human Services shall analyze 
     the data collected by the Secretary of Health and Human 
     Services from the records made available to the Secretary 
     under section 1886(h)(4)(E) of the Social Security Act, as 
     amended by subsection (a), in order to assess the extent to 
     which there is an increase in time spent by medical residents 
     in training in nonprovider settings as a result of the 
     amendments made by this section. Not later than 4 years after 
     the date of the enactment of this Act, the Inspector General 
     shall submit a report to Congress on such analysis and 
     assessment.
       (d) Demonstration Project for Approved Teaching Health 
     Centers.--
       (1) In general.--The Secretary of Health and Human Services 
     shall conduct a demonstration project under which an approved 
     teaching health center (as defined in paragraph (3)) would be 
     eligible for payment under subsections (h) and (k) of section 
     1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts 
     for its own direct costs of graduate medical education 
     activities for primary care residents, as well as for the 
     direct costs of graduate medical education activities of its 
     contracting hospital for such residents, in a manner similar 
     to the manner in which such payments would be made to a 
     hospital if the hospital were to operate such a program.
       (2) Conditions.--Under the demonstration project--
       (A) an approved teaching health center shall contract with 
     an accredited teaching hospital to carry out the inpatient 
     responsibilities of the primary care residency program of the 
     hospital involved and is responsible for payment to the 
     hospital for the hospital's costs of the salary and fringe 
     benefits for residents in the program;
       (B) the number of primary care residents of the center 
     shall not count against the contracting hospital's resident 
     limit; and
       (C) the contracting hospital shall agree not to diminish 
     the number of residents in its primary care residency 
     training program.
       (3) Approved teaching health center defined.--In this 
     subsection, the term ``approved teaching health center'' 
     means a nonprovider setting, such as a Federally qualified 
     health center or rural health clinic (as defined in section 
     1861(aa) of the Social Security Act), that develops and 
     operates an accredited primary care residency program for 
     which funding would be available if it were operated by a 
     hospital.

     SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND 
                   SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

       (a) Direct GME.--Section 1886(h) of the Social Security Act 
     (42 U.S.C. 1395ww(h)) is amended--
       (1) in paragraph (4)(E), as amended by section 1502(a)--
       (A) in clause (i), by striking ``Such rules'' and inserting 
     ``Subject to clause (ii), such rules''; and
       (B) by adding at the end the following new clause:
       ``(ii) Treatment of certain nonprovider and didactic 
     activities.--Such rules shall provide that all time spent by 
     an intern or resident in an approved medical residency 
     training program in a nonprovider setting that is primarily 
     engaged in furnishing patient care (as defined in paragraph 
     (5)(K)) in nonpatient care activities, such as didactic 
     conferences and seminars, but not including research not 
     associated with the treatment or diagnosis of a particular 
     patient, as such time and activities are defined by the 
     Secretary, shall be counted toward the determination of full-
     time equivalency.'';
       (2) in paragraph (4), by adding at the end the following 
     new subparagraph:
       ``(I) Treatment of certain time in approved medical 
     residency training programing.--In determining the hospital's 
     number of full-time equivalent residents for purposes of this 
     subsection, all the time that is spent by an intern or 
     resident in an approved medical residency training program on 
     vacation, sick leave, or other approved leave, as such time 
     is defined by the Secretary, and that does not prolong the 
     total time the resident is participating in the approved 
     program beyond the normal duration of the program shall be 
     counted toward the determination of full-time equivalency.''; 
     and
       (3) in paragraph (5), by adding at the end the following 
     new subparagraph:
       ``(K) Nonprovider setting that is primarily engaged in 
     furnishing patient care.--The term `nonprovider setting that 
     is primarily engaged in furnishing patient care' means a 
     nonprovider setting in which the primary activity is the care 
     and treatment of patients, as defined by the Secretary.''.
       (b) IME Determinations.--Section 1886(d)(5)(B) of such Act 
     (42 U.S.C. 1395ww(d)(5)(B)), as amended by section 1501(b), 
     is amended by adding at the end the following new clause:
       ``(xi)(I) The provisions of subparagraph (I) of subsection 
     (h)(4) shall apply under this subparagraph in the same manner 
     as they apply under such subsection.
       ``(II) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by

[[Page 27316]]

     an intern or resident in an approved medical residency 
     training program in nonpatient care activities, such as 
     didactic conferences and seminars, as such time and 
     activities are defined by the Secretary, that occurs in the 
     hospital shall be counted toward the determination of full-
     time equivalency if the hospital--
       ``(aa) is recognized as a subsection (d) hospital;
       ``(bb) is recognized as a subsection (d) Puerto Rico 
     hospital;
       ``(cc) is reimbursed under a reimbursement system 
     authorized under section 1814(b)(3); or
       ``(dd) is a provider-based hospital outpatient department.
       ``(III) In determining the hospital's number of full-time 
     equivalent residents for purposes of this subparagraph, all 
     the time spent by an intern or resident in an approved 
     medical residency training program in research activities 
     that are not associated with the treatment or diagnosis of a 
     particular patient, as such time and activities are defined 
     by the Secretary, shall not be counted toward the 
     determination of full-time equivalency.''.
       (c) Effective Dates; Application.--
       (1) In general.--Except as otherwise provided, the 
     Secretary of Health and Human Services shall implement the 
     amendments made by this section in a manner so as to apply to 
     cost reporting periods beginning on or after January 1, 1983.
       (2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social 
     Security Act, as added by subsection (a)(1)(B), shall apply 
     to cost reporting periods beginning on or after July 1, 2008.
       (3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social 
     Security Act, as added by subsection (b), shall apply to cost 
     reporting periods beginning on or after October 1, 2001. Such 
     section, as so added, shall not give rise to any inference on 
     how the law in effect prior to such date should be 
     interpreted.
       (4) Application.--The amendments made by this section shall 
     not be applied in a manner that requires reopening of any 
     settled hospital cost reports as to which there is not a 
     jurisdictionally proper appeal pending as of the date of the 
     enactment of this Act on the issue of payment for indirect 
     costs of medical education under section 1886(d)(5)(B) of the 
     Social Security Act or for direct graduate medical education 
     costs under section 1886(h) of such Act.

     SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED 
                   HOSPITALS.

       (a) Direct GME.--Section 1886(h)(4)(H) of the Social 
     Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) is amended 
     by adding at the end the following new clause:
       ``(vi) Redistribution of residency slots after a hospital 
     closes.--

       ``(I) In general.--The Secretary shall, by regulation, 
     establish a process consistent with subclauses (II) and (III) 
     under which, in the case where a hospital (other than a 
     hospital described in clause (v)) with an approved medical 
     residency program in a State closes on or after the date that 
     is 2 years before the date of the enactment of this clause, 
     the Secretary shall increase the otherwise applicable 
     resident limit under this paragraph for other hospitals in 
     the State in accordance with this clause.
       ``(II) Process for hospitals in certain areas.--In 
     determining for which hospitals the increase in the otherwise 
     applicable resident limit described in subclause (I) is 
     provided, the Secretary shall establish a process to provide 
     for such increase to one or more hospitals located in the 
     State. Such process shall take into consideration the 
     recommendations submitted to the Secretary by the senior 
     health official (as designated by the chief executive officer 
     of such State) if such recommendations are submitted not 
     later than 180 days after the date of the hospital closure 
     involved (or, in the case of a hospital that closed after the 
     date that is 2 years before the date of the enactment of this 
     clause, 180 days after such date of enactment).
       ``(III) Limitation.--The estimated aggregate number of 
     increases in the otherwise applicable resident limits for 
     hospitals under this clause shall be equal to the estimated 
     number of resident positions in the approved medical 
     residency programs that closed on or after the date described 
     in subclause (I).''.

       (b) No Effect on Temporary FTE Cap Adjustments.--The 
     amendments made by this section shall not effect any 
     temporary adjustment to a hospital's FTE cap under section 
     413.79(h) of title 42, Code of Federal Regulations (as in 
     effect on the date of enactment of this Act) and shall not 
     affect the application of section 1886(h)(4)(H)(v) of the 
     Social Security Act.
       (c) Conforming Amendments.--
       (1) Section 422(b)(2) of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173), as amended by section 1501(c), is amended by striking 
     ``(7) and'' and inserting ``(4)(H)(vi), (7), and''.
       (2) Section 1886(h)(7)(E) of the Social Security Act (42 
     U.S.C. 1395ww(h)(7)(E)) is amended by inserting ``or under 
     paragraph (4)(H)(vi)'' after ``under this paragraph''.

     SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL 
                   RESIDENCY TRAINING.

       (a) Specification of Goals for Approved Medical Residency 
     Training Programs.--Section 1886(h)(1) of the Social Security 
     Act (42 U.S.C. 1395ww(h)(1)) is amended--
       (1) by designating the matter beginning with 
     ``Notwithstanding'' as a subparagraph (A) with the heading 
     ``In general.--'' and with appropriate indentation; and
       (2) by adding at the end the following new subparagraph:
       ``(B) Goals and accountability for approved medical 
     residency training programs.--The goals of medical residency 
     training programs are to foster a physician workforce so that 
     physicians are trained to be able to do the following:
       ``(i) Work effectively in various health care delivery 
     settings, such as nonprovider settings.
       ``(ii) Coordinate patient care within and across settings 
     relevant to their specialties.
       ``(iii) Understand the relevant cost and value of various 
     diagnostic and treatment options.
       ``(iv) Work in inter-professional teams and multi-
     disciplinary team-based models in provider and nonprovider 
     settings to enhance safety and improve quality of patient 
     care.
       ``(v) Be knowledgeable in methods of identifying systematic 
     errors in health care delivery and in implementing systematic 
     solutions in case of such errors, including experience and 
     participation in continuous quality improvement projects to 
     improve health outcomes of the population the physicians 
     serve.
       ``(vi) Be meaningful EHR users (as determined under section 
     1848(o)(2)) in the delivery of care and in improving the 
     quality of the health of the community and the individuals 
     that the hospital serves.''
       (b) GAO Study on Evaluation of Training Programs.--
       (1) In general.--The Comptroller General of the United 
     States shall conduct a study to evaluate the extent to which 
     medical residency training programs--
       (A) are meeting the goals described in section 
     1886(h)(1)(B) of the Social Security Act, as added by 
     subsection (a), in a range of residency programs, including 
     primary care and other specialties; and
       (B) have the appropriate faculty expertise to teach the 
     topics required to achieve such goals.
       (2) Report.--Not later than 18 months after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report on such study and shall include in such 
     report recommendations as to how medical residency training 
     programs could be further encouraged to meet such goals 
     through means such as--
       (A) development of curriculum requirements; and
       (B) assessment of the accreditation processes of the 
     Accreditation Council for Graduate Medical Education and the 
     American Osteopathic Association and effectiveness of those 
     processes in accrediting medical residency programs that meet 
     the goals referred to in paragraph (1)(A).

                      TITLE VI--PROGRAM INTEGRITY

     Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse

     SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO FIGHT FRAUD 
                   AND ABUSE.

       (a) In General.--Section 1817(k) of the Social Security Act 
     (42 U.S.C. 1395i(k)) is amended--
       (1) by adding at the end the following new paragraph:
       ``(7) Additional funding.--In addition to the funds 
     otherwise appropriated to the Account from the Trust Fund 
     under paragraphs (3) and (4) and for purposes described in 
     paragraphs (3)(C) and (4)(A), there are hereby appropriated 
     an additional $100,000,000 to such Account from such Trust 
     Fund for each fiscal year beginning with 2011. The funds 
     appropriated under this paragraph shall be allocated in the 
     same proportion as the total funding appropriated with 
     respect to paragraphs (3)(A) and (4)(A) was allocated with 
     respect to fiscal year 2010, and shall be available without 
     further appropriation until expended.''.
       (2) in paragraph (4)(A)--
       (A) by inserting ``for activities described in paragraph 
     (3)(C) and'' after ``necessary''; and
       (B) by inserting ``until expended'' after 
     ``appropriation''.
       (b) Flexibility in Pursuing Fraud and Abuse.--Section 
     1893(a) of the Social Security Act (42 U.S.C. 1395ddd(a)) is 
     amended by inserting ``, or otherwise,'' after ``entities''.

           Subtitle B--Enhanced Penalties for Fraud and Abuse

     SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON 
                   PROVIDER OR SUPPLIER ENROLLMENT APPLICATIONS.

       (a) In General.--Section 1128A(a) of the Social Security 
     Act (42 U.S.C. 1320a-7a(a)) is amended--
       (1) in paragraph (1)(D), by striking all that follows ``in 
     which the person was excluded'' and inserting ``under Federal 
     law from the Federal health care program under which the 
     claim was made, or'';
       (2) by striking ``or'' at the end of paragraph (6);
       (3) in paragraph (7), by inserting at the end ``or'';
       (4) by inserting after paragraph (7) the following new 
     paragraph:

[[Page 27317]]

       ``(8) knowingly makes or causes to be made any false 
     statement, omission, or misrepresentation of a material fact 
     in any application, agreement, bid, or contract to 
     participate or enroll as a provider of services or supplier 
     under a Federal health care program, including managed care 
     organizations under title XIX, Medicare Advantage 
     organizations under part C of title XVIII, prescription drug 
     plan sponsors under part D of title XVIII, and entities that 
     apply to participate as providers of services or suppliers in 
     such managed care organizations and such plans;'';
       (5) in the matter following paragraph (8), as inserted by 
     paragraph (4), by striking ``or in cases under paragraph (7), 
     $50,000 for each such act)'' and inserting ``in cases under 
     paragraph (7), $50,000 for each such act, or in cases under 
     paragraph (8), $50,000 for each false statement, omission, or 
     misrepresentation of a material fact)''; and
       (6) in the second sentence, by striking ``for a lawful 
     purpose)'' and inserting ``for a lawful purpose, or in cases 
     under paragraph (8), an assessment of not more than 3 times 
     the amount claimed as the result of the false statement, 
     omission, or misrepresentation of material fact claimed by a 
     provider of services or supplier whose application to 
     participate contained such false statement, omission, or 
     misrepresentation)''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to acts committed on or after January 1, 2010.

     SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE 
                   STATEMENTS MATERIAL TO A FALSE CLAIM.

       (a) In General.--Section 1128A(a) of the Social Security 
     Act (42 U.S.C. 1320a-7a(a)), as amended by section 1611, is 
     further amended--
       (1) in paragraph (7), by striking ``or'' at the end;
       (2) in paragraph (8), by inserting ``or'' at the end; and
       (3) by inserting after paragraph (8), the following new 
     paragraph:
       ``(9) knowingly makes, uses, or causes to be made or used, 
     a false record or statement material to a false or fraudulent 
     claim for payment for items and services furnished under a 
     Federal health care program;''; and
       (4) in the matter following paragraph (9), as inserted by 
     paragraph (3)--
       (A) by striking ``or in cases under paragraph (8)'' and 
     inserting ``in cases under paragraph (8)''; and
       (B) by striking ``a material fact)'' and inserting ``a 
     material fact, in cases under paragraph (9), $50,000 for each 
     false record or statement)''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to acts committed on or after January 1, 2010.

     SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.

       (a) In General.--Section 1128A(a) of the Social Security 
     Act (42 U.S.C. 1320a-7a(a)), as amended by sections 1611 and 
     1612, is further amended--
       (1) in paragraph (8), by striking ``or'' at the end;
       (2) in paragraph (9), by inserting ``or'' at the end;
       (3) by inserting after paragraph (9) the following new 
     paragraph:
       ``(10) fails to grant timely access, upon reasonable 
     request (as defined by the Secretary in regulations), to the 
     Inspector General of the Department of Health and Human 
     Services, for the purpose of audits, investigations, 
     evaluations, or other statutory functions of the Inspector 
     General of the Department of Health and Human Services;''; 
     and
       (4) in the matter following paragraph (10), as inserted by 
     paragraph (3), by inserting ``, or in cases under paragraph 
     (10), $15,000 for each day of the failure described in such 
     paragraph'' after ``false record or statement''.
       (b) Ensuring Timely Inspections Relating to Contracts With 
     MA Organizations.--Section 1857(d)(2) of such Act (42 U.S.C. 
     1395w-27(d)(2)) is amended--
       (1) in subparagraph (A), by inserting ``timely'' before 
     ``inspect''; and
       (2) in subparagraph (B), by inserting ``timely'' before 
     ``audit and inspect''.
       (c) Effective Date.--The amendments made by subsection (a) 
     shall apply to violations committed on or after January 1, 
     2010.

     SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.

       (a) Medicare.--Part A of title XVIII of the Social Security 
     Act is amended by inserting after section 1819 the following 
     new section:

     ``SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.

       ``(a) In General.--If the Secretary determines on the basis 
     of a survey or otherwise, that a hospice program that is 
     certified for participation under this title has demonstrated 
     a substandard quality of care and failed to meet such other 
     requirements as the Secretary may find necessary in the 
     interest of the health and safety of the individuals who are 
     provided care and services by the agency or organization 
     involved and determines--
       ``(1) that the deficiencies involved immediately jeopardize 
     the health and safety of the individuals to whom the program 
     furnishes items and services, the Secretary shall take 
     immediate action to remove the jeopardy and correct the 
     deficiencies through the remedy specified in subsection 
     (b)(2)(A)(iii) or terminate the certification of the program, 
     and may provide, in addition, for 1 or more of the other 
     remedies described in subsection (b)(2)(A); or
       ``(2) that the deficiencies involved do not immediately 
     jeopardize the health and safety of the individuals to whom 
     the program furnishes items and services, the Secretary may--
       ``(A) impose intermediate sanctions developed pursuant to 
     subsection (b), in lieu of terminating the certification of 
     the program; and
       ``(B) if, after such a period of intermediate sanctions, 
     the program is still not in compliance with such 
     requirements, the Secretary shall terminate the certification 
     of the program.

     If the Secretary determines that a hospice program that is 
     certified for participation under this title is in compliance 
     with such requirements but, as of a previous period, was not 
     in compliance with such requirements, the Secretary may 
     provide for a civil money penalty under subsection 
     (b)(2)(A)(i) for the days in which it finds that the program 
     was not in compliance with such requirements.
       ``(b) Intermediate Sanctions.--
       ``(1) Development and implementation.--The Secretary shall 
     develop and implement, by not later than July 1, 2012--
       ``(A) a range of intermediate sanctions to apply to hospice 
     programs under the conditions described in subsection (a), 
     and
       ``(B) appropriate procedures for appealing determinations 
     relating to the imposition of such sanctions.
       ``(2) Specified sanctions.--
       ``(A) In general.--The intermediate sanctions developed 
     under paragraph (1) may include--
       ``(i) civil money penalties in an amount not to exceed 
     $10,000 for each day of noncompliance or, in the case of a 
     per instance penalty applied by the Secretary, not to exceed 
     $25,000,
       ``(ii) denial of all or part of the payments to which a 
     hospice program would otherwise be entitled under this title 
     with respect to items and services furnished by a hospice 
     program on or after the date on which the Secretary 
     determines that intermediate sanctions should be imposed 
     pursuant to subsection (a)(2),
       ``(iii) the appointment of temporary management to oversee 
     the operation of the hospice program and to protect and 
     assure the health and safety of the individuals under the 
     care of the program while improvements are made,
       ``(iv) corrective action plans, and
       ``(v) in-service training for staff.

     The provisions of section 1128A (other than subsections (a) 
     and (b)) shall apply to a civil money penalty under clause 
     (i) in the same manner as such provisions apply to a penalty 
     or proceeding under section 1128A(a). The temporary 
     management under clause (iii) shall not be terminated until 
     the Secretary has determined that the program has the 
     management capability to ensure continued compliance with all 
     requirements referred to in that clause.
       ``(B) Clarification.--The sanctions specified in 
     subparagraph (A) are in addition to sanctions otherwise 
     available under State or Federal law and shall not be 
     construed as limiting other remedies, including any remedy 
     available to an individual at common law.
       ``(C) Commencement of payment.--A denial of payment under 
     subparagraph (A)(ii) shall terminate when the Secretary 
     determines that the hospice program no longer demonstrates a 
     substandard quality of care and meets such other requirements 
     as the Secretary may find necessary in the interest of the 
     health and safety of the individuals who are provided care 
     and services by the agency or organization involved.
       ``(3) Secretarial authority.--The Secretary shall develop 
     and implement, by not later than July 1, 2011, specific 
     procedures with respect to the conditions under which each of 
     the intermediate sanctions developed under paragraph (1) is 
     to be applied, including the amount of any fines and the 
     severity of each of these sanctions. Such procedures shall be 
     designed so as to minimize the time between identification of 
     deficiencies and imposition of these sanctions and shall 
     provide for the imposition of incrementally more severe fines 
     for repeated or uncorrected deficiencies.''.
       (b) Application to Medicaid.--Section 1905(o) of the Social 
     Security Act (42 U.S.C. 1396d(o)) is amended by adding at the 
     end the following new paragraph:
       ``(4) The provisions of section 1819A shall apply to a 
     hospice program providing hospice care under this title in 
     the same manner as such provisions apply to a hospice program 
     providing hospice care under title XVIII.''.
       (c) Application to CHIP.--Title XXI of the Social Security 
     Act is amended by adding at the end the following new 
     section:

     ``SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.

       ``The provisions of section 1819A shall apply to a hospice 
     program providing hospice care under this title in the same 
     manner such provisions apply to a hospice program providing 
     hospice care under title XVIII.''.

[[Page 27318]]



     SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM 
                   PROGRAM PARTICIPATION.

       (a) In General.--Section 1128A(a) of the Social Security 
     Act (42 U.S.C. 1320a-7a(a)), as amended by the previous 
     sections, is further amended--
       (1) by striking ``or'' at the end of paragraph (9);
       (2) by inserting ``or'' at the end of paragraph (10);
       (3) by inserting after paragraph (10) the following new 
     paragraph:
       ``(11) orders or prescribes an item or service, including 
     without limitation home health care, diagnostic and clinical 
     lab tests, prescription drugs, durable medical equipment, 
     ambulance services, physical or occupational therapy, or any 
     other item or service, during a period when the person has 
     been excluded from participation in a Federal health care 
     program, and the person knows or should know that a claim for 
     such item or service will be presented to such a program;''; 
     and
       (4) in the matter following paragraph (11), as inserted by 
     paragraph (2), by striking ``$15,000 for each day of the 
     failure described in such paragraph'' and inserting ``$15,000 
     for each day of the failure described in such paragraph, or 
     in cases under paragraph (11), $50,000 for each order or 
     prescription for an item or service by an excluded 
     individual''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to violations committed on or after January 1, 
     2010.

     SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE 
                   INFORMATION BY MEDICARE ADVANTAGE AND PART D 
                   PLANS.

       (a) In General.--Section 1857(g)(2)(A) of the Social 
     Security Act (42 U.S.C. 1395w--27(g)(2)(A)) is amended by 
     inserting ``except with respect to a determination under 
     subparagraph (E), an assessment of not more than 3 times the 
     amount claimed by such plan or plan sponsor based upon the 
     misrepresentation or falsified information involved,'' after 
     ``for each such determination,''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to violations committed on or after January 1, 
     2010.

     SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART 
                   D MARKETING VIOLATIONS.

       (a) In General.--Section 1857(g)(1) of the Social Security 
     Act (42 U.S.C. 1395w--27(g)(1)), as amended by section 
     1221(b), is amended--
       (1) in subparagraph (G), by striking ``or'' at the end;
       (2) by inserting after subparagraph (H) the following new 
     subparagraphs:
       ``(I) except as provided under subparagraph (C) or (D) of 
     section 1860D-1(b)(1), enrolls an individual in any plan 
     under this part without the prior consent of the individual 
     or the designee of the individual;
       ``(J) transfers an individual enrolled under this part from 
     one plan to another without the prior consent of the 
     individual or the designee of the individual or solely for 
     the purpose of earning a commission;
       ``(K) fails to comply with marketing restrictions described 
     in subsections (h) and (j) of section 1851 or applicable 
     implementing regulations or guidance; or
       ``(L) employs or contracts with any individual or entity 
     who engages in the conduct described in subparagraphs (A) 
     through (K) of this paragraph;''; and
       (3) by adding at the end the following new sentence: ``The 
     Secretary may provide, in addition to any other remedies 
     authorized by law, for any of the remedies described in 
     paragraph (2), if the Secretary determines that any employee 
     or agent of such organization, or any provider or supplier 
     who contracts with such organization, has engaged in any 
     conduct described in subparagraphs (A) through (L) of this 
     paragraph.''
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to violations committed on or after January 1, 
     2010.

     SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM 
                   AUDITS.

       (a) In General.--Section 1128(b)(2) of the Social Security 
     Act (42 U.S.C. 1320a-7(b)(2)) is amended--
       (1) in the heading, by inserting ``or audit'' after 
     ``investigation''; and
       (2) by striking ``investigation into'' and all that follows 
     through the period and inserting ``investigation or audit 
     related to--''
       ``(i) any offense described in paragraph (1) or in 
     subsection (a); or
       ``(ii) the use of funds received, directly or indirectly, 
     from any Federal health care program (as defined in section 
     1128B(f)).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to violations committed on or after January 1, 
     2010.

     SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM 
                   PARTICIPATION IN MEDICARE AND STATE HEALTH CARE 
                   PROGRAMS.

       (a) In General.--Section 1128(c) of the Social Security 
     Act, as previously amended by this division, is further 
     amended--
       (1) in the heading, by striking ``and Period'' and 
     inserting ``Period, and Effect''; and
       (2) by adding at the end the following new paragraph:
       ``(4)(A) For purposes of this Act, subject to subparagraph 
     (C), the effect of exclusion is that no payment may be made 
     by any Federal health care program (as defined in section 
     1128B(f)) with respect to any item or service furnished--
       ``(i) by an excluded individual or entity; or
       ``(ii) at the medical direction or on the prescription of a 
     physician or other authorized individual when the person 
     submitting a claim for such item or service knew or had 
     reason to know of the exclusion of such individual.
       ``(B) For purposes of this section and sections 1128A and 
     1128B, subject to subparagraph (C), an item or service has 
     been furnished by an individual or entity if the individual 
     or entity directly or indirectly provided, ordered, 
     manufactured, distributed, prescribed, or otherwise supplied 
     the item or service regardless of how the item or service was 
     paid for by a Federal health care program or to whom such 
     payment was made.
       ``(C)(i) Payment may be made under a Federal health care 
     program for emergency items or services (not including items 
     or services furnished in an emergency room of a hospital) 
     furnished by an excluded individual or entity, or at the 
     medical direction or on the prescription of an excluded 
     physician or other authorized individual during the period of 
     such individual's exclusion.
       ``(ii) In the case that an individual eligible for benefits 
     under title XVIII or XIX submits a claim for payment for 
     items or services furnished by an excluded individual or 
     entity, and such individual eligible for such benefits did 
     not know or have reason to know that such excluded individual 
     or entity was so excluded, then, notwithstanding such 
     exclusion, payment shall be made for such items or services. 
     In such case the Secretary shall notify such individual 
     eligible for such benefits of the exclusion of the individual 
     or entity furnishing the items or services. Payment shall not 
     be made for items or services furnished by an excluded 
     individual or entity to an individual eligible for such 
     benefits after a reasonable time (as determined by the 
     Secretary in regulations) after the Secretary has notified 
     the individual eligible for such benefits of the exclusion of 
     the individual or entity furnishing the items or services.
       ``(iii) In the case that a claim for payment for items or 
     services furnished by an excluded individual or entity is 
     submitted by an individual or entity other than an individual 
     eligible for benefits under title XVIII or XIX or the 
     excluded individual or entity, and the Secretary determines 
     that the individual or entity that submitted the claim took 
     reasonable steps to learn of the exclusion and reasonably 
     relied upon inaccurate or misleading information from the 
     relevant Federal health care program or its contractor, the 
     Secretary may waive repayment of the amount paid in violation 
     of the exclusion to the individual or entity that submitted 
     the claim for the items or services furnished by the excluded 
     individual or entity. If a Federal health care program 
     contractor provided inaccurate or misleading information that 
     resulted in the waiver of an overpayment under this clause, 
     the Secretary shall take appropriate action to recover the 
     improperly paid amount from the contractor.''.

     SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL HEALTH CARE 
                   PROGRAMS OFFICERS AND OWNERS OF ENTITIES 
                   CONVICTED OF FRAUD.

       Section 1128(b)(15)(A) of the Social Security Act (42 
     U.S.C. 1320a-7(b)(15)(A)) is amended--
       (1) in clause (i)--
       (A) by striking ``has'' and inserting ``had''; and
       (B) by striking ``sanctioned entity and who knows or should 
     know (as defined in section 1128A(i)(6)) of'' and inserting 
     ``sanctioned entity at the time of, and who knew or should 
     have known (as defined in section 1128A(i)(6)) of,'' ; and
       (2) in clause (ii)--
       (A) by striking ``is an officer'' and inserting ``was an 
     officer''; and
       (B) by inserting before the period the following: ``at the 
     time of the action constituting the basis for the conviction 
     or exclusion described in subparagraph (B)''.

     SEC. 1621. SELF-REFERRAL DISCLOSURE PROTOCOL.

       (a) Development of Self-referral Disclosure Protocol.--
       (1) In general.--The Secretary of Health and Human 
     Services, in cooperation with the Inspector General of the 
     Department of Health and Human Services, shall establish, not 
     later than 6 months after the date of the enactment of this 
     Act, a protocol to enable health care providers of services 
     and suppliers to disclose an actual or potential violation of 
     section 1877 of the Social Security Act (42 U.S.C. 1395nn) 
     pursuant to a self-referral disclosure protocol (in this 
     section referred to as an ``SRDP''). The SRDP shall include 
     direction to health care providers of services and suppliers 
     on--
       (A) a specific person, official, or office to whom such 
     disclosures shall be made; and
       (B) instruction on the implication of the SRDP on corporate 
     integrity agreements and corporate compliance agreements.
       (2) Publication on internet website of srdp information.--
     The Secretary shall post information on the public Internet 
     website of the Centers for Medicare & Medicaid Services to 
     inform relevant stakeholders of how

[[Page 27319]]

     to disclose actual or potential violations pursuant to an 
     SRDP.
       (3) Relation to advisory opinions.--The SRDP shall be 
     separate from the advisory opinion process set forth in 
     regulations implementing section 1877(g) of the Social 
     Security Act.
       (b) Reduction in Amounts Owed.--The Secretary is authorized 
     to reduce the amount due and owing for all violations under 
     section 1877 of the Social Security Act to an amount less 
     than that specified in subsection (g) of such section. In 
     establishing such amount for a violation, the Secretary may 
     consider the following factors:
       (1) The nature and extent of the improper or illegal 
     practice.
       (2) The timeliness of such self-disclosure.
       (3) The cooperation in providing additional information 
     related to the disclosure.
       (4) Such other factors as the Secretary considers 
     appropriate.
       (c) Report.--Not later than 18 months after the date on 
     which the SRDP protocol is established under subsection 
     (a)(1), the Secretary shall submit to Congress a report on 
     the implementation of this section. Such report shall 
     include--
       (1) the number of health care providers of services and 
     suppliers making disclosures pursuant to an SRDP;
       (2) the amounts collected pursuant to the SRDP;
       (3) the types of violations reported under the SRDP; and
       (4) such other information as may be necessary to evaluate 
     the impact of this section.
       (d) Relation to Other Law and Regulation.--Nothing in this 
     section shall affect the application of section 1128G(c) of 
     the Social Security Act, as added by section 1641, except, in 
     the case of a health care provider of services or supplier 
     who is a person (as defined in paragraph (4) of such section 
     1128G(c)) who discloses an overpayment (as defined in such 
     paragraph) to the Secretary of Health and Human Services 
     pursuant to a SRDP established under this section, the 60-day 
     period described in paragraph (2) of such section 1128G(c) 
     shall be extended with respect to the return of an 
     overpayment to the extent necessary for the Secretary to 
     determine pursuant to the SRDP the amount due and owing.

         Subtitle C--Enhanced Program and Provider Protections

     SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.

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

     ``SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN 
                   THE MEDICARE, MEDICAID, AND CHIP PROGRAMS.

       ``(a) Certain Authorized Screening, Enhanced Oversight 
     Periods, and Enrollment Moratoria.--
       ``(1) In general.--For periods beginning after January 1, 
     2011, in the case that the Secretary determines there is a 
     significant risk of fraudulent activity (as determined by the 
     Secretary based on relevant complaints, reports, referrals by 
     law enforcement or other sources, data analysis, trending 
     information, or claims submissions by providers of services 
     and suppliers) with respect to a category of provider of 
     services or supplier of items or services, including a 
     category within a geographic area, under title XVIII, XIX, or 
     XXI, the Secretary may impose any of the following 
     requirements with respect to a provider of services or a 
     supplier (whether such provider or supplier is initially 
     enrolling in the program or is renewing such enrollment):
       ``(A) Screening under paragraph (2).
       ``(B) Enhanced oversight periods under paragraph (3).
       ``(C) Enrollment moratoria under paragraph (4).

     In applying this subsection for purposes of title XIX and XXI 
     the Secretary may require a State to carry out the provisions 
     of this subsection as a requirement of the State plan under 
     title XIX or the child health plan under title XXI. Actions 
     taken and determinations made under this subsection shall not 
     be subject to review by a judicial tribunal.
       ``(2) Screening.--For purposes of paragraph (1), the 
     Secretary shall establish procedures under which screening is 
     conducted with respect to providers of services and suppliers 
     described in such paragraph. Such screening may include--
       ``(A) licensing board checks;
       ``(B) screening against the list of individuals and 
     entities excluded from the program under title XVIII, XIX, or 
     XXI;
       ``(C) the excluded provider list system;
       ``(D) background checks; and
       ``(E) unannounced pre-enrollment or other site visits.
       ``(3) Enhanced oversight period.--For purposes of paragraph 
     (1), the Secretary shall establish procedures to provide for 
     a period of not less than 30 days and not more than 365 days 
     during which providers of services and suppliers described in 
     such paragraph, as the Secretary determines appropriate, 
     would be subject to enhanced oversight, such as required or 
     unannounced (or required and unannounced) site visits or 
     inspections, prepayment review, enhanced review of claims, 
     and such other actions as specified by the Secretary, under 
     the programs under titles XVIII, XIX, and XXI. Under such 
     procedures, the Secretary may extend such period for more 
     than 365 days if the Secretary determines that after the 
     initial period such additional period of oversight is 
     necessary.
       ``(4) Moratorium on enrollment of providers and 
     suppliers.--For purposes of paragraph (1), the Secretary, 
     based upon a finding of a risk of serious ongoing fraud 
     within a program under title XVIII, XIX, or XXI, may impose a 
     moratorium on the enrollment of providers of services and 
     suppliers within a category of providers of services and 
     suppliers (including a category within a specific geographic 
     area) under such title. Such a moratorium may only be imposed 
     if the Secretary makes a determination that the moratorium 
     would not adversely impact access of individuals to care 
     under such program.
       ``(5) 90-day period of enhanced oversight for initial 
     claims of dme suppliers.--For periods beginning after January 
     1, 2011, if the Secretary determines under paragraph (1) that 
     there is a significant risk of fraudulent activity among 
     suppliers of durable medical equipment, in the case of a 
     supplier of durable medical equipment who is within a 
     category or geographic area under title XVIII identified 
     pursuant to such determination and who is initially enrolling 
     under such title, the Secretary shall, notwithstanding 
     section 1842(c)(2), withhold payment under such title with 
     respect to durable medical equipment furnished by such 
     supplier during the 90-day period beginning on the date of 
     the first submission of a claim under such title for durable 
     medical equipment furnished by such supplier.
       ``(6) Clarification.--Nothing in this subsection shall be 
     interpreted to preclude or limit the ability of a State to 
     engage in provider screening or enhanced provider oversight 
     activities beyond those required by the Secretary.''.
       (b) Conforming Amendments.--
       (1) Medicaid.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 42 U.S.C. 1396a(a)) is amended--
       (A) in paragraph (23), by inserting before the semicolon at 
     the end the following: ``or by a person to whom or entity to 
     which a moratorium under section 1128G(a)(4) is applied 
     during the period of such moratorium'';
       (B) in paragraph (72); by striking at the end ``and'';
       (C) in paragraph (73), by striking the period at the end 
     and inserting ``; and''; and
       (D) by adding after paragraph (73) the following new 
     paragraph:
       ``(74) provide that the State will enforce any 
     determination made by the Secretary under subsection (a) of 
     section 1128G (relating to a significant risk of fraudulent 
     activity with respect to a category of provider or supplier 
     described in such subsection (a) through use of the 
     appropriate procedures described in such subsection (a)), and 
     that the State will carry out any activities as required by 
     the Secretary for purposes of such subsection (a).''.
       (2) CHIP.--Section 2102 of such Act (42 U.S.C. 1397bb) is 
     amended by adding at the end the following new subsection:
       ``(d) Program Integrity.--A State child health plan shall 
     include a description of the procedures to be used by the 
     State--
       ``(1) to enforce any determination made by the Secretary 
     under subsection (a) of section 1128G (relating to a 
     significant risk of fraudulent activity with respect to a 
     category of provider or supplier described in such subsection 
     through use of the appropriate procedures described in such 
     subsection); and
       ``(2) to carry out any activities as required by the 
     Secretary for purposes of such subsection.''.
       (3) Medicare.--Section 1866(j) of such Act (42 U.S.C. 
     1395cc(j)) is amended by adding at the end the following new 
     paragraph:
       ``(3) Program integrity.--The provisions of section 
     1128G(a) apply to enrollments and renewals of enrollments of 
     providers of services and suppliers under this title.''.

     SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM 
                   DISCLOSURE REQUIREMENTS RELATING TO PREVIOUS 
                   AFFILIATIONS.

       (a) In General.--Section 1128G of the Social Security Act, 
     as inserted by section 1631, is amended by adding at the end 
     the following new subsection:
       ``(b) Enhanced Program Disclosure Requirements.--
       ``(1) Disclosure.--A provider of services or supplier who 
     submits on or after July 1, 2011, an application for 
     enrollment and renewing enrollment in a program under title 
     XVIII, XIX, or XXI shall disclose (in a form and manner 
     determined by the Secretary) any current affiliation or 
     affiliation within the previous 10-year period with a 
     provider of services or supplier that has uncollected debt or 
     with a person or entity that has been suspended or excluded 
     under such program, subject to a payment suspension, or has 
     had its billing privileges revoked.
       ``(2) Enhanced safeguards.--If the Secretary determines 
     that such previous affiliation of such provider or supplier 
     poses a risk of fraud, waste, or abuse, the Secretary may 
     apply such enhanced safeguards as the Secretary determines 
     necessary to reduce such risk associated with such provider 
     or supplier enrolling or participating in the program under 
     title XVIII, XIX, or XXI.

[[Page 27320]]

     Such safeguards may include enhanced oversight, such as 
     enhanced screening of claims, required or unannounced (or 
     required and unannounced) site visits or inspections, 
     additional information reporting requirements, and 
     conditioning such enrollment on the provision of a surety 
     bond.
       ``(3) Authority to deny participation.--If the Secretary 
     determines that there has been at least one such affiliation 
     and that such affiliation or affiliations, as applicable, of 
     such provider or supplier poses a serious risk of fraud, 
     waste, or abuse, the Secretary may deny the application of 
     such provider or supplier.''.
       (b) Conforming Amendments.--
       (1) Medicaid.--Paragraph (74) of section 1902(a) of such 
     Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is 
     amended--
       (A) by inserting ``or subsection (b) of such section 
     (relating to disclosure requirements)'' before ``, and that 
     the State''; and
       (B) by inserting before the period the following: ``and 
     apply any enhanced safeguards, with respect to a provider or 
     supplier described in such subsection (b), as the Secretary 
     determines necessary under such subsection (b)''.
       (2) CHIP.--Subsection (d) of section 2102 of such Act (42 
     U.S.C. 1397bb), as added by section 1631(b)(2), is amended--
       (A) in paragraph (1), by striking at the end ``and'';
       (B) in paragraph (2) by striking the period at the end and 
     inserting ``; and''' and
       (C) by adding at the end the following new paragraph:
       ``(3) to enforce any determination made by the Secretary 
     under subsection (b) of section 1128G (relating to disclosure 
     requirements) and to apply any enhanced safeguards, with 
     respect to a provider or supplier described in such 
     subsection, as the Secretary determines necessary under such 
     subsection.''.

     SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN 
                   EVALUATION AND MANAGEMENT SERVICES.

       Section 1848 of the Social Security Act (42 U.S.C. 1395w-
     4), as amended by section 4101 of the HITECH Act (Public Law 
     111-5), is amended by adding at the end the following new 
     subsection:
       ``(p) Payment Modifier for Certain Evaluation and 
     Management Services.--The Secretary shall establish a payment 
     modifier under the fee schedule under this section for 
     evaluation and management services (as specified in section 
     1842(b)(16)(B)(ii)) that result in the ordering of additional 
     services (such as lab tests), the prescription of drugs, the 
     furnishing or ordering of durable medical equipment in order 
     to enable better monitoring of claims for payment for such 
     additional services under this title, or the ordering, 
     furnishing, or prescribing of other items and services 
     determined by the Secretary to pose a high risk of waste, 
     fraud, and abuse. The Secretary may require providers of 
     services or suppliers to report such modifier in claims 
     submitted for payment.''.

     SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE 
                   INTEGRITY PROGRAM.

       (a) In General.--Section 1893(c) of the Social Security Act 
     (42 U.S.C. 1395ddd(c)) is amended--
       (1) in paragraph (3), by striking at the end ``and'';
       (2) by redesignating paragraph (4) as paragraph (5); and
       (3) by inserting after paragraph (3) the following new 
     paragraph:
       ``(4) for the contract year beginning in 2011 and each 
     subsequent contract year, the entity provides assurances to 
     the satisfaction of the Secretary that the entity will 
     conduct periodic evaluations of the effectiveness of the 
     activities carried out by such entity under the Program and 
     will submit to the Secretary an annual report on such 
     activities; and''.
       (b) Reference to Medicaid Integrity Program.--For a similar 
     provision with respect to the Medicaid Integrity Program, see 
     section 1752.

     SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS 
                   TO REDUCE WASTE, FRAUD, AND ABUSE.

       (a) In General.--Section 1866(j) of the Social Security Act 
     (42 U.S.C. 42 U.S.C. 1395cc(j)), as amended by section 
     1631(d)(3), is further amended by adding at the end the 
     following new paragraph:
       ``(4) Compliance programs for providers of services and 
     suppliers.--
       ``(A) In general.--The Secretary may not enroll (or renew 
     the enrollment of) a provider of services or a supplier 
     (other than a physician or a skilled nursing facility) under 
     this title if such provider of services or supplier fails to, 
     subject to subparagraph (E), establish a compliance program 
     that contains the core elements established under 
     subparagraph (B) and certify in a manner determined by the 
     Secretary, that the provider or suppler has established such 
     a program.
       ``(B) Establishment of core elements.--The Secretary, in 
     consultation with the Inspector General of the Department of 
     Health and Human Services, shall establish core elements for 
     a compliance program under subparagraph (A). Such elements 
     may include written policies, procedures, and standards of 
     conduct, a designated compliance officer and a compliance 
     committee; effective training and education pertaining to 
     fraud, waste, and abuse for the organization's employees, and 
     contractors; a confidential or anonymous mechanism, such as a 
     hotline, to receive compliance questions and reports of 
     fraud, waste, or abuse; disciplinary guidelines for 
     enforcement of standards; internal monitoring and auditing 
     procedures, including monitoring and auditing of contractors; 
     procedures for ensuring prompt responses to detected offenses 
     and development of corrective action initiatives, including 
     responses to potential offenses; and procedures to return all 
     identified overpayments to the programs under this title, 
     title XIX, and title XXI.
       ``(C) Timeline for implementation.--The Secretary shall 
     determine a timeline for the establishment of the core 
     elements under subparagraph (B) and the date on which a 
     provider of services and suppliers (other than physicians and 
     skilled nursing facilities) shall be required to have 
     established such a program for purposes of this subsection.
       ``(D) Pilot program.--The Secretary may conduct a pilot 
     program on the application of this subsection with respect to 
     a category of providers of services or suppliers (other than 
     physicians and skilled nursing facilities) that the Secretary 
     determines to be a category which is at high risk for waste, 
     fraud, and abuse before implementing the requirements of this 
     subsection to all providers of services and suppliers 
     described in subparagraph (C).
       ``(E) Treatment of skilled nursing facilities.--For the 
     requirement for skilled nursing facilities to establish 
     compliance and ethics programs see section 1819(d)(1)(C).
       ``(F) Construction.--Nothing in this subsection exempts a 
     physician from participating in a compliance program 
     established by a health care provider or other entity with 
     which the physician is employed, under contract, or 
     affiliated if such compliance is required by such provider or 
     entity.''.
       (b) Reference to Similar Medicaid Provision.--For a similar 
     provision with respect to the Medicaid program under title 
     XIX of the Social Security Act, see section 1753.

     SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS 
                   REDUCED TO NOT MORE THAN 12 MONTHS.

       (a) Purpose.--In general, the 36-month period currently 
     allowed for claims filing under parts A, B, C, and, D of 
     title XVIII of the Social Security Act presents opportunities 
     for fraud schemes in which processing patterns of the Centers 
     for Medicare & Medicaid Services can be observed and 
     exploited. Narrowing the window for claims processing will 
     not overburden providers and will reduce fraud and abuse.
       (b) Reducing Maximum Period for Submission.--
       (1) Part a.--Section 1814(a) of the Social Security Act (42 
     U.S.C. 1395f(a)) is amended--
       (A) in paragraph (1), by striking ``period of 3 calendar 
     years'' and all that follows and inserting ``period of 1 
     calendar year from which such services are furnished; and''; 
     and
       (B) by adding at the end the following new sentence: ``In 
     applying paragraph (1), the Secretary may specify exceptions 
     to the 1 calendar year period specified in such paragraph.''.
       (2) Part b.--Section 1835(a) of such Act (42 U.S.C. 
     1395n(a)) is amended--
       (A) in paragraph (1), by striking ``period of 3 calendar 
     years'' and all that follows and inserting ``period of 1 
     calendar year from which such services are furnished; and''; 
     and
       (B) by adding at the end the following new sentence: ``In 
     applying paragraph (1), the Secretary may specify exceptions 
     to the 1 calendar year period specified in such paragraph.''.
       (3) Parts c and d.--Section 1857(d) of such Act is amended 
     by adding at the end the following new paragraph:
       ``(7) Period for submission of claims.--The contract shall 
     require an MA organization or PDP sponsor to require any 
     provider of services under contract with, in partnership 
     with, or affiliated with such organization or sponsor to 
     ensure that, with respect to items and services furnished by 
     such provider to an enrollee of such organization, written 
     request, signed by enrollee, except in cases in which the 
     Secretary finds it impracticable for the enrollee to do so, 
     is filed for payment for such items and services in such 
     form, in such manner, and by such person or persons as the 
     Secretary may by regulation prescribe, no later than the 
     close of the 1 calendar year period after such items and 
     services are furnished. In applying the previous sentence, 
     the Secretary may specify exceptions to the 1 calendar year 
     period specified.''.
       (c) Effective Date.--The amendments made by subsection (b) 
     shall be effective for items and services furnished on or 
     after January 1, 2011.

     SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR 
                   HOME HEALTH SERVICES REQUIRED TO BE MEDICARE 
                   ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS.

       (a) DME.--Section 1834(a)(11)(B) of the Social Security Act 
     (42 U.S.C. 1395m(a)(11)(B)) is amended by striking 
     ``physician'' and inserting ``physician enrolled under 
     section 1866(j) or other professional, as determined by the 
     Secretary''.
       (b) Home Health Services.--
       (1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C. 
     1395(a)(2)) is amended in the matter preceding subparagraph 
     (A) by inserting

[[Page 27321]]

     ``in the case of services described in subparagraph (C), a 
     physician enrolled under section 1866(j) or other 
     professional, as determined by the Secretary,'' before ``or, 
     in the case of services''.
       (2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C. 
     1395n(a)(2)) is amended in the matter preceding subparagraph 
     (A) by inserting ``, or in the case of services described in 
     subparagraph (A), a physician enrolled under section 1866(j) 
     or other professional, as determined by the Secretary,'' 
     after ``a physician''.
       (c) Discretion to Expand Application.--The Secretary may 
     extend the requirement applied by the amendments made by 
     subsections (a) and (b) to durable medical equipment and home 
     health services (relating to requiring certifications and 
     written orders to be made by enrolled physicians and health 
     professions) to other categories of items or services under 
     this title, including covered part D drugs as defined in 
     section 1860D-2(e), if the Secretary determines that such 
     application would help to reduce the risk of waste, fraud, 
     and abuse with respect to such other categories under title 
     XVIII of the Social Security Act.
       (d) Effective Date.--The amendments made by this section 
     shall apply to written orders and certifications made on or 
     after July 1, 2010.

     SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE 
                   DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH 
                   RISK OF WASTE AND ABUSE.

       (a) Physicians and Other Suppliers.--Section 1842(h) of the 
     Social Security Act is further amended by adding at the end 
     the following new paragraph
       ``(9) The Secretary may disenroll, for a period of not more 
     than one year for each act, a physician or supplier under 
     section 1866(j) if such physician or supplier fails to 
     maintain and, upon request of the Secretary, provide access 
     to documentation relating to written orders or requests for 
     payment for durable medical equipment, certifications for 
     home health services, or referrals for other items or 
     services written or ordered by such physician or supplier 
     under this title, as specified by the Secretary.''.
       (b) Providers of Services.--Section 1866(a)(1) of such Act 
     (42 U.S.C. 1395cc), is amended--
       (1) in subparagraph (U), by striking at the end ``and'';
       (2) in subparagraph (V), by striking the period at the end 
     and adding ``; and''; and
       (3) by adding at the end the following new subparagraph:
       ``(W) maintain and, upon request of the Secretary, provide 
     access to documentation relating to written orders or 
     requests for payment for durable medical equipment, 
     certifications for home health services, or referrals for 
     other items or services written or ordered by the provider 
     under this title, as specified by the Secretary.''.
       (c) OIG Permissive Exclusion Authority.--Section 
     1128(b)(11) of the Social Security Act (42 U.S.C. 1320a-
     7(b)(11)) is amended by inserting ``, ordering, referring for 
     furnishing, or certifying the need for'' after 
     ``furnishing''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to orders, certifications, and referrals made on 
     or after January 1, 2010.

     SEC. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT REQUIRED 
                   BEFORE ELIGIBILITY CERTIFICATIONS FOR HOME 
                   HEALTH SERVICES OR DURABLE MEDICAL EQUIPMENT.

       (a) Condition of Payment for Home Health Services.--
       (1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
       (A) by striking ``and such services'' and inserting ``such 
     services''; and
       (B) by inserting after ``care of a physician'' the 
     following: ``, and, in the case of a certification or 
     recertification made by a physician after January 1, 2010, 
     prior to making such certification the physician must 
     document that the physician has had a face-to-face encounter 
     (including through use of telehealth and other than with 
     respect to encounters that are incident to services involved) 
     with the individual during the 6-month period preceding such 
     certification, or other reasonable timeframe as determined by 
     the Secretary''.
       (2) Part b.--Section 1835(a)(2)(A) of the Social Security 
     Act is amended--
       (A) by striking ``and'' before ``(iii)''; and
       (B) by inserting after ``care of a physician'' the 
     following: ``, and (iv) in the case of a certification or 
     recertification after January 1, 2010, prior to making such 
     certification the physician must document that the physician 
     has had a face-to-face encounter (including through use of 
     telehealth and other than with respect to encounters that are 
     incident to services involved) with the individual during the 
     6-month period preceding such certification or 
     recertification, or other reasonable timeframe as determined 
     by the Secretary''.
       (b) Condition of Payment for Durable Medical Equipment.--
     Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C. 
     1395m(a)(11)(B)) is amended by adding before the period at 
     the end the following: ``and shall require that any written 
     order required for payment under this subsection be written 
     only pursuant to the eligible health care professional 
     authorized to make such written order documenting that such 
     professional has had a face-to-face encounter (including 
     through use of telehealth and other than with respect to 
     encounters that are incident to services involved) with the 
     individual involved during the 6-month period preceding such 
     written order, or other reasonable timeframe as determined by 
     the Secretary''.
       (c) Application to Other Areas Under Medicare.--The 
     Secretary may apply a face-to-face encounter requirement 
     similar to the requirement described in the amendments made 
     by subsections (a) and (b) to other items and services for 
     which payment is provided under title XVIII of the Social 
     Security Act based upon a finding that such a decision would 
     reduce the risk of waste, fraud, or abuse.
       (d) Application to Medicaid and CHIP.--The face-to-face 
     encounter requirements described in the amendments made by 
     subsections (a) and (b) and any expanded application of 
     similar requirements pursuant to subsection (c) shall apply 
     with respect to a certification or recertification for home 
     health services under title XIX or XXI of the Social Security 
     Act, a written order for durable medical equipment under such 
     title, and any other applicable item or service identified 
     pursuant to subsection (c) for which payment is made under 
     such title, respectively, in the same manner and to the same 
     extent as such requirements apply in the case of such a 
     certification or recertification, written order, or other 
     applicable item or service so identified, respectively, under 
     title XVIII of such Act.

     SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO 
                   PROGRAM EXCLUSION INVESTIGATIONS.

       (a) In General.--Section 1128(f) of the Social Security Act 
     (42 U.S.C. 1320a-7(f)) is amended by adding at the end the 
     following new paragraph:
       ``(4) The provisions of subsections (d) and (e) of section 
     205 shall apply with respect to this section to the same 
     extent as they are applicable with respect to title II. The 
     Secretary may delegate the authority granted by section 
     205(d) (as made applicable to this section) to the Inspector 
     General of the Department of Health and Human Services or the 
     Administrator of the Centers for Medicare & Medicaid Services 
     for purposes of any investigation under this section.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to investigations beginning on or after January 
     1, 2010.

     SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID 
                   OVERPAYMENTS.

       Section 1128G of the Social Security Act, as inserted by 
     section 1631 and amended by section 1632, is further amended 
     by adding at the end the following new subsection:
       ``(c) Reports on and Repayment of Overpayments Identified 
     Through Internal Audits and Reviews.--
       ``(1) Reporting and returning overpayments.--If a person 
     knows of an overpayment, the person must--
       ``(A) report and return the overpayment to the Secretary, 
     the State, an intermediary, a carrier, or a contractor, as 
     appropriate, at the correct address, and
       ``(B) notify the Secretary, the State, intermediary, 
     carrier, or contractor to whom the overpayment was returned 
     in writing of the reason for the overpayment.
       ``(2) Timing.--Subject to section 1620(d) of the Affordable 
     Health Care for America Act, an overpayment must be reported 
     and returned under paragraph (1)(A) by not later than the 
     date that is 60 days after the date the person knows of the 
     overpayment.
     Any known overpayment retained later than the applicable date 
     specified in this paragraph creates an obligation as defined 
     in section 3729(b)(3) of title 31 of the United States Code.
       ``(3) Clarification.--Repayment of any overpayments (or 
     refunding by withholding of future payments) by a provider of 
     services or supplier does not otherwise limit the provider or 
     supplier's potential liability for administrative obligations 
     such as applicable interests, fines, and penalties or civil 
     or criminal sanctions involving the same claim if it is 
     determined later that the reason for the overpayment was 
     related to fraud or other intentional conduct by the provider 
     or supplier or the employees or agents of such provider or 
     supplier.
       ``(4) Definitions.--In this subsection:
       ``(A) Knows.--The term `knows' has the meaning given the 
     terms `knowing' and `knowingly' in section 3729(b) of title 
     31 of the United States Code.
       ``(B) Overpayment.--The term ``overpayment'' means any 
     funds that a person receives or retains under title XVIII, 
     XIX, or XXI to which the person, after applicable 
     reconciliation (pursuant to the applicable existing process 
     under the respective title), is not entitled under such 
     title.
       ``(C) Person.--The term `person' means a provider of 
     services, supplier, Medicaid managed care organization (as 
     defined in section 1903(m)(1)(A)), Medicare Advantage 
     organization (as defined in section 1859(a)(1)), or PDP 
     sponsor (as defined in section 1860D-41(a)(13)), but 
     excluding a beneficiary.''.

[[Page 27322]]



     SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG 
                   EXCLUSIONS TO BENEFICIARIES OF ANY FEDERAL 
                   HEALTH CARE PROGRAM.

       Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 
     1320a-7(c)(3)(B)) is amended by striking ``individuals 
     entitled to benefits under part A of title XVIII or enrolled 
     under part B of such title, or both'' and inserting 
     ``beneficiaries (as defined in section 1128A(i)(5)) of that 
     program''.

     SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS 
                   FACILITIES.

       Section 1881(b) of the Social Security Act (42 U.S.C. 
     1395rr(b)) is amended by adding at the end the following new 
     paragraph:
       ``(15) For purposes of evaluating or auditing payments made 
     to renal dialysis facilities for items and services under 
     this section under paragraph (1), each such renal dialysis 
     facility, upon the request of the Secretary, shall provide to 
     the Secretary access to information relating to any ownership 
     or compensation arrangement between such facility and the 
     medical director of such facility or between such facility 
     and any physician.''.

     SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE 
                   PAYEES REQUIRED TO REGISTER UNDER MEDICARE.

       (a) Medicare.--Section 1866(j)(1) of the Social Security 
     Act (42 U.S.C. 1395cc(j)(1)) is amended by adding at the end 
     the following new subparagraph:
       ``(D) Billing agents and clearinghouses required to be 
     registered under medicare.--Any agent, clearinghouse, or 
     other alternate payee that submits claims on behalf of a 
     health care provider must be registered with the Secretary in 
     a form and manner specified by the Secretary.''.
       (b) Medicaid.--For a similar provision with respect to the 
     Medicaid program under title XIX of the Social Security Act, 
     see section 1759.
       (c) Effective Date.--The amendment made by subsection (a) 
     shall apply to claims submitted on or after January 1, 2012.

     SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO FALSE 
                   CLAIMS ACT AMENDMENTS.

       Section 1128A of the Social Security Act, as amended by 
     sections 1611, 1612, 1613, and 1615, is further amended--
       (1) in subsection (a)--
       (A) in paragraph (1), by striking ``to an officer, 
     employee, or agent of the United States, or of any department 
     or agency thereof, or of any State agency (as defined in 
     subsection (i)(1))'';
       (B) in paragraph (4)--
       (i) in the matter preceding subparagraph (A), by striking 
     ``participating in a program under title XVIII or a State 
     health care program'' and inserting ``participating in a 
     Federal health care program (as defined in section 
     1128B(f))''; and
       (ii) in subparagraph (A), by striking ``title XVIII or a 
     State health care program'' and inserting ``a Federal health 
     care program (as defined in section 1128B(f))'';
       (C) by striking ``or'' at the end of paragraph (10);
       (D) by inserting after paragraph (11) the following new 
     paragraphs:
       ``(12) conspires to commit a violation of this section; or
       ``(13) knowingly makes, uses, or causes to be made or used, 
     a false record or statement material to an obligation to pay 
     or transmit money or property to a Federal health care 
     program, or knowingly conceals or knowingly and improperly 
     avoids or decreases an obligation to pay or transmit money or 
     property to a Federal health care program;''; and
       (E) in the matter following paragraph (13), as inserted by 
     subparagraph (D)--
       (i) by striking ``or'' before ``in cases under paragraph 
     (11)''; and
       (ii) by inserting ``, in cases under paragraph (12), 
     $50,000 for any violation described in this section committed 
     in furtherance of the conspiracy involved; or in cases under 
     paragraph (13), $50,000 for each false record or statement, 
     or concealment, avoidance, or decrease'' after ``by an 
     excluded individual''; and
       (F) in the second sentence, by striking ``such false 
     statement, omission, or misrepresentation)'' and inserting 
     ``such false statement or misrepresentation, in cases under 
     paragraph (12), an assessment of not more than 3 times the 
     total amount that would otherwise apply for any violation 
     described in this section committed in furtherance of the 
     conspiracy involved, or in cases under paragraph (13), an 
     assessment of not more than 3 times the total amount of the 
     obligation to which the false record or statement was 
     material or that was avoided or decreased)''.
       (2) in subsection (c)(1), by striking ``six years'' and 
     inserting ``10 years''; and
       (3) in subsection (i)--
       (A) by amending paragraph (2) to read as follows:
       ``(2) The term `claim' means any application, request, or 
     demand, whether under contract, or otherwise, for money or 
     property for items and services under a Federal health care 
     program (as defined in section 1128B(f)), whether or not the 
     United States or a State agency has title to the money or 
     property, that--
       ``(A) is presented or caused to be presented to an officer, 
     employee, or agent of the United States, or of any department 
     or agency thereof, or of any State agency (as defined in 
     subsection (i)(1)); or
       ``(B) is made to a contractor, grantee, or other recipient 
     if the money or property is to be spent or used on the 
     Federal health care program's behalf or to advance a Federal 
     health care program interest, and if the Federal health care 
     program--
       ``(i) provides or has provided any portion of the money or 
     property requested or demanded; or
       ``(ii) will reimburse such contractor, grantee, or other 
     recipient for any portion of the money or property which is 
     requested or demanded.'';
       (B) by amending paragraph (3) to read as follows:
       ``(3) The term `item or service' means, without limitation, 
     any medical, social, management, administrative, or other 
     item or service used in connection with or directly or 
     indirectly related to a Federal health care program.'';
       (C) in paragraph (6)--
       (i) in subparagraph (C), by striking at the end ``or'';
       (ii) in the first subparagraph (D), by striking at the end 
     the period and inserting ``; or''; and
       (iii) by redesignating the second subparagraph (D) as a 
     subparagraph (E);
       (D) by amending paragraph (7) to read as follows:
       ``(7) The terms `knowing', `knowingly', and `should know' 
     mean that a person, with respect to information--
       ``(A) has actual knowledge of the information;
       ``(B) acts in deliberate ignorance of the truth or falsity 
     of the information; or
       ``(C) acts in reckless disregard of the truth or falsity of 
     the information;
     and require no proof of specific intent to defraud.''; and
       (E) by adding at the end the following new paragraphs:
       ``(8) The term `obligation' means an established duty, 
     whether or not fixed, arising from an express or implied 
     contractual, grantor-grantee, or licensor-licensee 
     relationship, from a fee-based or similar relationship, from 
     statute or regulation, or from the retention of any 
     overpayment.
       ``(9) The term `material' means having a natural tendency 
     to influence, or be capable of influencing, the payment or 
     receipt of money or property.''.

     SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAYMENTS UNDER 
                   MEDICARE TO BE MADE THROUGH DIRECT DEPOSIT OR 
                   ELECTRONIC FUNDS TRANSFER (EFT) AT INSURED 
                   DEPOSITORY INSTITUTIONS.

       (a) Medicare.--Section 1874 of the Social Security Act (42 
     U.S.C. 1395kk) is amended by adding at the end the following 
     new subsection:
       ``(e) Limitation on Payment to Providers of Services and 
     Suppliers.--No payment shall be made under this title for 
     items and services furnished by a provider of services or 
     supplier unless each payment to the provider of services or 
     supplier is in the form of direct deposit or electronic funds 
     transfer to the provider of services' or supplier's account, 
     as applicable, at a depository institution (as defined in 
     section 19(b)(1)(A) of the Federal Reserve Act.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to each payment made to a provider of services, 
     provider, or supplier on or after such date (not later than 
     July 1, 2012) as the Secretary of Health and Human Services 
     shall specify, regardless of when the items and services for 
     which such payment is made were furnished.

     SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH CHOICES 
                   ADMINISTRATION.

       (a) Establishment; Appointment.--There is hereby 
     established an Office of Inspector General for the Health 
     Choices Administration, to be headed by the Inspector General 
     for the Health Choices Administration to be appointed by the 
     President, by and with the advice and consent of the Senate.
       (b) Amendments to the Inspector General Act of 1978.--
       (1) Application to health choices administration.--Section 
     12 of the Inspector General Act of 1978 (5 U.S.C. App.) is 
     amended--
       (A) in paragraph (1), by striking ``or the Federal 
     Cochairpersons of the Commissions established under section 
     15301 of title 40, United States Code'' and inserting ``the 
     Federal Cochairpersons of the Commissions established under 
     section 15301 of title 40, United States Code; or the 
     Commissioner of the Health Choices Administration established 
     under section 241 of the Affordable Health Care for America 
     Act''; and
       (B) in paragraph (2), by striking ``or the Commissions 
     established under section 15301 of title 40, United States 
     Code'' and inserting ``the Commissions established under 
     section 15301 of title 40, United States Code, or the Health 
     Choices Administration established under section 241 of the 
     Affordable Health Care for America Act''.
       (2) Special provisions relating to health choices 
     administration and hhs.--The Inspector General Act of 1978 (5 
     U.S.C. App.) is further amended by inserting after section 8L 
     the following new section:

[[Page 27323]]



     ``SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH CHOICES 
                   ADMINISTRATION AND THE DEPARTMENT OF HEALTH AND 
                   HUMAN SERVICES.

       ``(a) The Inspector General of the Health Choices 
     Administration shall--
       ``(1) have the authority to conduct, supervise, and 
     coordinate audits, evaluations, and investigations of the 
     programs and operations of the Health Choices Administration 
     established under section 241 of the Affordable Health Care 
     for America Act, including matters relating to fraud, abuse, 
     and misconduct in connection with the admission and continued 
     participation of any health benefits plan participating in 
     the Health Insurance Exchange established under section 301 
     of such Act;
       ``(2) have the authority to conduct audits, evaluations, 
     and investigations relating to any private Exchange-
     participating health benefits plan, as defined in section 
     201(c) of such Act;
       ``(3) have the authority, in consultation with the Office 
     of Inspector General for the Department of Health and Human 
     Services and subject to subsection (b), to conduct audits, 
     evaluations, and investigations relating to the public health 
     insurance option established under section 321 of such Act; 
     and
       ``(4) have access to all relevant records necessary to 
     carry out this section, including records relating to claims 
     paid by Exchange-participating health benefits plans.
       ``(b) Authority granted to the Health Choices 
     Administration and the Inspector General of the Health 
     Choices Administration by the Affordable Health Care for 
     America Act does not limit the duties, authorities, and 
     responsibilities of the Office of Inspector General for the 
     Department of Health and Human Services, as in existence as 
     of the date of the enactment of the Affordable Health Care 
     for America Act, to oversee programs and operations of such 
     department. The Office of Inspector General for the 
     Department of Health and Human Services retains primary 
     jurisdiction over fraud and abuse in connection with payments 
     made under the public health insurance option established 
     under section 321 of such Act and administered by the 
     Department of Health and Human Services.''.
       (3) Application of rule of construction.--Section 8J of the 
     Inspector General Act of 1978 (5 U.S.C. App.) is amended by 
     striking ``or 8H'' and inserting ``, 8H, or 8M''.
       (c) Effective Date.--The provisions of and amendments made 
     by this section shall take effect on the date of the 
     enactment of this Act.

 Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and 
                                 Abuse

     SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD, 
                   WASTE, AND ABUSE.

       (a) GAO Access.--Subchapter II of chapter 7 of title 31, 
     United States Code, is amended by adding at the end the 
     following:

     ``Sec. 721. Access to certain information

       ``No provision of the Social Security Act shall be 
     construed to limit, amend, or supersede the authority of the 
     Comptroller General to obtain any information, to inspect any 
     record, or to interview any officer or employee under section 
     716 of this title, including with respect to any information 
     disclosed to or obtained by the Secretary of Health and Human 
     Services under part C or D of title XVIII of the Social 
     Security Act.''.
       (b) Access to Medicare Part D Data Program Integrity 
     Purposes.--
       (1) Provision of information as condition of payment.--
     Section 1860D-15(d)(2)(B) of the Social Security Act (42 
     U.S.C. 1395w-115(d)(2)(B)) is amended--
       (A) by striking ``may be used by officers'' and all that 
     follows through the period and inserting ``may be used by--
     ''; and
       (B) by adding at the end the following clauses:
       ``(i) officers, employees, and contractors of the 
     Department of Health and Human Services only for the purposes 
     of, and to the extent necessary in, carrying out this 
     section; and
       ``(ii) the Inspector General of the Department of Health 
     and Human Services, the Administrator of the Centers for 
     Medicare & Medicaid Services, and the Attorney General only 
     for the purposes of protecting the integrity of the programs 
     under this title and title XIX; conducting the activities 
     described in section 1893 and subparagraphs (A) through (E) 
     of section 1128C(a)(1); and for investigation, audit, 
     evaluation, oversight, 
     and law enforcement purposes to the extent consistent with 
     applicable law.''.
       (2) General disclosure of information.--Section 1860D-
     15(f)(2) of the Social Security Act (42 U.S.C. 1395w-
     115(f)(2)) is amended--
       (A) by striking ``may be used by officers'' and all that 
     follows through the period and inserting ``may be used by--
     ''; and
       (B) by adding at the end the following subparagraphs:
       ``(A) officers, employees, and contractors of the 
     Department of Health and Human Services only for the purposes 
     of, and to the extent necessary in, carrying out this 
     section; and
       ``(B) the Inspector General of the Department of Health and 
     Human Services, the Administrator of the Centers for Medicare 
     & Medicaid Services, and the Attorney General only for the 
     purposes of protecting the integrity of the programs under 
     this title and title XIX; conducting the activities described 
     in section 1893 and subparagraphs (A) through (E) of section 
     1128C(a)(1); and for investigation, audit, evaluation, 
     oversight, 
     and law enforcement purposes to the extent consistent with 
     applicable law.''.

     SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE 
                   INTEGRITY AND PROTECTION DATA BANK AND THE 
                   NATIONAL PRACTITIONER DATA BANK.

       (a) In General.--To eliminate duplication between the 
     Healthcare Integrity and Protection Data Bank (HIPDB) 
     established under section 1128E of the Social Security Act 
     and the National Practitioner Data Bank (NPBD) established 
     under the Health Care Quality Improvement Act of 1986, 
     section 1128E of the Social Security Act (42 U.S.C. 1320a-7e) 
     is amended--
       (1) in subsection (a), by striking ``Not later than'' and 
     inserting ``Subject to subsection (h), not later than'';
       (2) in the first sentence of subsection (d)(2), by striking 
     ``(other than with respect to requests by Federal 
     agencies)''; and
       (3) by adding at the end the following new subsection:
       ``(h) Sunset of the Healthcare Integrity and Protection 
     Data Bank; Transition Process.--Effective upon the enactment 
     of this subsection, the Secretary shall implement a process 
     to eliminate duplication between the Healthcare Integrity and 
     Protection Data Bank (in this subsection referred to as the 
     `HIPDB' established pursuant to subsection (a) and the 
     National Practitioner Data Bank (in this subsection referred 
     to as the `NPDB') as implemented under the Health Care 
     Quality Improvement Act of 1986 and section 1921 of this Act, 
     including systems testing necessary to ensure that 
     information formerly collected in the HIPDB will be 
     accessible through the NPDB, and other activities necessary 
     to eliminate duplication between the two data banks. Upon the 
     completion of such process, notwithstanding any other 
     provision of law, the Secretary shall cease the operation of 
     the HIPDB and shall collect information required to be 
     reported under the preceding provisions of this section in 
     the NPDB. Except as otherwise provided in this subsection, 
     the provisions of subsections (a) through (g) shall continue 
     to apply with respect to the reporting of (or failure to 
     report), access to, and other treatment of the information 
     specified in this section.''.
       (b) Elimination of the Responsibility of the HHS Office of 
     the Inspector General.--Section 1128C(a)(1) of the Social 
     Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
       (1) in subparagraph (C), by adding at the end ``and'';
       (2) in subparagraph (D), by striking at the end ``, and'' 
     and inserting a period; and
       (3) by striking subparagraph (E).
       (c) Special Provision for Access to the National 
     Practitioner Data Bank by the Department of Veterans 
     Affairs.--
       (1) In general.--Notwithstanding any other provision of 
     law, during the one year period that begins on the effective 
     date specified in subsection (e)(1), the information 
     described in paragraph (2) shall be available from the 
     National Practitioner Data Bank (described in section 1921 of 
     the Social Security Act) to the Secretary of Veterans Affairs 
     without charge.
       (2) Information described.--For purposes of paragraph (1), 
     the information described in this paragraph is the 
     information that would, but for the amendments made by this 
     section, have been available to the Secretary of Veterans 
     Affairs from the Healthcare Integrity and Protection Data 
     Bank.
       (d) Funding.--Notwithstanding any provisions of this Act, 
     sections 1128E(d)(2) and 1817(k)(3) of the Social Security 
     Act, or any other provision of law, there shall be available 
     for carrying out the transition process under section 
     1128E(h) of the Social Security Act over the period required 
     to complete such process, and for operation of the National 
     Practitioner Data Bank until such process is completed, 
     without fiscal year limitation--
       (1) any fees collected pursuant to section 1128E(d)(2) of 
     such Act; and
       (2) such additional amounts as necessary, from 
     appropriations available to the Secretary and to the Office 
     of the Inspector General of the Department of Health and 
     Human Services under clauses (i) and (ii), respectively, of 
     section 1817(k)(3)(A) of such Act, for costs of such 
     activities during the first 12 months following the date of 
     the enactment of this Act.
       (e) Effective Date.--The amendments made--
       (1) by subsection (a)(2) shall take effect on the first day 
     after the Secretary of Health and Human Services certifies 
     that the process implemented pursuant to section 1128E(h) of 
     the Social Security Act (as added by subsection (a)(3)) is 
     complete; and
       (2) by subsection (b) shall take effect on the earlier of 
     the date specified in paragraph (1) or the first day of the 
     second succeeding fiscal year after the fiscal year during 
     which this Act is enacted.

[[Page 27324]]



     SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY 
                   STANDARDS.

       The provisions of sections 262(a) and 264 of the Health 
     Insurance Portability and Accountability Act of 1996 (and 
     standards promulgated pursuant to such sections) and the 
     Privacy Act of 1974 shall apply with respect to the 
     provisions of this subtitle and amendments made by this 
     subtitle.

     SEC. 1654. DISCLOSURE OF MEDICARE FRAUD AND ABUSE HOTLINE 
                   NUMBER ON EXPLANATION OF BENEFITS.

       (a) In General.--Section 1804 of the Social Security Act 
     (42 U.S.C. 1395b-2) is amended by adding at the end the 
     following new subsection:
       ``(d) Any statement or notice containing an explanation of 
     the benefits available under this title, including the notice 
     required by subsection (a), distributed for periods after 
     July 1, 2011, shall prominently display in a manner 
     prescribed by the Secretary a separate toll-free telephone 
     number maintained by the Secretary for the receipt of 
     complaints and information about waste, fraud, and abuse in 
     the provision or billing of services under this title.''.
       (b) Conforming Amendments.--Section 1804(c) of the Social 
     Security Act (42 U.S.C. 1395b-2(c)) is amended--
       (1) in paragraph (2), by adding ``and'' at the end;
       (2) in paragraph (3), by striking ``; and'' and inserting a 
     period; and
       (3) by striking paragraph (4).

                      TITLE VII--MEDICAID AND CHIP

                 Subtitle A--Medicaid and Health Reform

     SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 150 
                   PERCENT OF THE FEDERAL POVERTY LEVEL.

       (a) Eligibility for Non-traditional Individuals With Income 
     Below 150 Percent of the Federal Poverty Level.--
       (1) Full medicaid benefits for non-medicare eligible 
     individuals.--Section 1902(a)(10)(A)(i) of the Social 
     Security Act (42 U.S.C. 1396b(a)(10)(A)(i)) is amended--
       (A) by striking ``or'' at the end of subclause (VI);
       (B) by adding ``or'' at the end of subclause (VII); and
       (C) by adding at the end the following new subclause:

       ``(VIII) who are under 65 years of age, who are not 
     described in a previous subclause of this clause, who are not 
     entitled to hospital insurance benefits under part A of title 
     XVIII, and whose family income (determined using 
     methodologies and procedures specified by the Secretary in 
     consultation with the Health Choices Commissioner) does not 
     exceed 150 percent of the income official poverty line (as 
     defined by the Office of Management and Budget, and revised 
     annually in accordance with section 673(2) of the Omnibus 
     Budget Reconciliation Act of 1981) applicable to a family of 
     the size involved;''.

       (2) Medicare cost sharing assistance for medicare-eligible 
     individuals.--Section 1902(a)(10)(E) of such Act (42 U.S.C. 
     1396b(a)(10)(E)) is amended--
       (A) in clause (iii), by striking ``and'' at the end;
       (B) in clause (iv), by adding ``and'' at the end; and
       (C) by adding at the end the following new clause:
       ``(v) for making medical assistance available for medicare 
     cost-sharing described in subparagraphs (B) and (C) of 
     section 1905(p)(3), for individuals under 65 years of age who 
     would be qualified medicare beneficiaries described in 
     section 1905(p)(1) but for the fact that their income exceeds 
     the income level established by the State under section 
     1905(p)(2) but is less than 150 percent of the official 
     poverty line (referred to in such section) for a family of 
     the size involved; and''.
       (3) Increased fmap for non-traditional full medicaid 
     eligible individuals.--Section 1905 of such Act (42 U.S.C. 
     1396d) is amended--
       (A) in the first sentence of subsection (b), by striking 
     ``and'' before ``(4)'' and by inserting before the period at 
     the end the following: ``, and (5) 100 percent (for periods 
     before 2015 and 91 percent for periods beginning with 2015) 
     with respect to amounts described in subsection (y)''; and
       (B) by adding at the end the following new subsection:
       ``(y) Additional Expenditures Subject to Increased FMAP.--
     For purposes of section 1905(b)(5), the amounts described in 
     this subsection are the following:
       ``(1) Amounts expended for medical assistance for 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i).''.
       (4) Construction.--Nothing in this subsection shall be 
     construed as not providing for coverage under subparagraph 
     (A)(i)(VIII) or (E)(v) of section 1902(a)(10) of the Social 
     Security Act, as added by paragraphs (1) and (2), or an 
     increased FMAP under the amendments made by paragraph (3), 
     for an individual who has been provided medical assistance 
     under title XIX of the Act under a demonstration waiver 
     approved under section 1115 of such Act or with State funds.
       (5) Conforming amendments.--
       (A) Section 1903(f)(4) of the Social Security Act (42 
     U.S.C. 1396b(f)(4)) is amended--
       (i) by inserting ``1902(a)(10)(A)(i)(VIII),'' after 
     ``1902(a)(10)(A)(i)(VII),''; and
       (ii) by inserting ``1902(a)(10)(E)(v),'' before 
     ``1905(p)(1)''.
       (B) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as 
     amended by sections 1714(a)(4) and 1731(c), is further 
     amended, in the matter preceding paragraph (1)--
       (i) by striking ``or'' at the end of clause (xiv);
       (ii) by adding ``or'' at the end of clause (xv); and
       (iii) by inserting after clause (xv) the following:
       ``(xvi) individuals described in section 
     1902(a)(10)(A)(i)(VIII),''.
       (b) Eligibility for Traditional Medicaid Eligible 
     Individuals With Income Not Exceeding 150 Percent of the 
     Federal Poverty Level .--
       (1) In general.--Section 1902(a)(10)(A)(i) of the Social 
     Security Act (42 U.S.C. 1396b(a)(10)(A)(i)), as amended by 
     subsection (a), is amended--
       (A) by striking ``or'' at the end of subclause (VII); and
       (B) by adding at the end the following new subclauses:

       ``(IX) who are over 18, and under 65 years of age, who 
     would be eligible for medical assistance under the State plan 
     under subclause (I) or section 1931 (based on the income 
     standards, methodologies, and procedures in effect as of June 
     16, 2009) but for income, who are in families whose income 
     does not exceed 150 percent of the income official poverty 
     line (as defined by the Office of Management and Budget, and 
     revised annually in accordance with section 673(2) of the 
     Omnibus Budget Reconciliation Act of 1981) applicable to a 
     family of the size involved; or
       ``(X) beginning with 2014, who are under 19, years of age, 
     who would be eligible for medical assistance under the State 
     plan under subclause (I), (IV) (insofar as it relates to 
     subsection (l)(1)(B)), (VI), or (VII) (based on the income 
     standards, methodologies, and procedures in effect as of June 
     16, 2009) but for income, who are in families whose income 
     does not exceed 150 percent of the income official poverty 
     line (as defined by the Office of Management and Budget, and 
     revised annually in accordance with section 673(2) of the 
     Omnibus Budget Reconciliation Act of 1981) applicable to a 
     family of the size involved; or
       ``(XI) beginning with 2014, who are under 19 years of age, 
     who are not described in subclause (X), and who would be 
     eligible for child health assistance under a State child 
     health plan insofar as such plan provides benefits under this 
     title (as described in section 2101(a)(2)) based on such plan 
     as in effect as of June 16, 2009; or''.

       (2) Increased fmap for certain traditional medicaid 
     eligible individuals.--
       (A) Increased fmap for adults.--Section 1905(y) of such Act 
     (42 U.S.C. 1396d(y)), as added by subsection (a)(2)(B), is 
     amended by inserting ``or (IX)'' after ``(VIII)''.
       (B) Enhanced fmap for children.--Section 1905(b)(4) of such 
     Act is amended by inserting ``1902(a)(10)(A)(i)(X), 
     1902(a)(10)(A)(i)(XI), or'' after ``on the basis of 
     section''.
       (3) Construction.--Nothing in this subsection shall be 
     construed as not providing for coverage under subclause (IX), 
     (X), or (XI) of section 1902(a)(10)(A)(i) of the Social 
     Security Act, as added by paragraph (1), or an increased or 
     enhanced FMAP under the amendments made by paragraph (2), for 
     an individual who has been provided medical assistance under 
     title XIX of the Act under a demonstration waiver approved 
     under section 1115 of such Act or with State funds.
       (4) Conforming amendment.--Section 1903(f)(4) of the Social 
     Security Act (42 U.S.C. 1396b(f)(4)), as amended by 
     subsection (a)(4), is amended by inserting 
     ``1902(a)(10)(A)(i)(IX), 1902(a)(10)(A)(i)(X), 
     1902(a)(10)(A)(i)(XI),'' after ``1902(a)(10)(A)(i)(VIII),''.
       (c) Increased Matching Rate for Temporary Coverage of 
     Certain Newborns.--Section 1905(y) of such Act, as added by 
     subsection (a)(3)(B), is amended by adding at the end the 
     following:
       ``(2) Amounts expended for medical assistance for children 
     described in section 305(d)(1) of the Affordable Health Care 
     for America Act during the time period specified in such 
     section.''.
       (d) Network Adequacy.--Section 1932(a)(2) of the Social 
     Security Act (42 U.S.C. 1396u-2(a)(2)) is amended by adding 
     at the end the following new subparagraph:
       ``(D) Enrollment of non-traditional medicaid eligibles.--A 
     State may not require under paragraph (1) the enrollment in a 
     managed care entity of an individual described in section 
     1902(a)(10)(A)(i)(VIII) unless the State demonstrates, to the 
     satisfaction of the Secretary, that the entity, through its 
     provider network and other arrangements, has the capacity to 
     meet the health, mental health, and substance abuse needs of 
     such individuals.''.
       (e) Effective Date.--The amendments made by this section 
     shall take effect on the first day of Y1, and shall apply 
     with respect to items and services furnished on or after such 
     date.

     SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CERTAIN 
                   MEDICAID ELIGIBLE INDIVIDUALS.

       (a) In General.--Title XIX of the Social Security Act is 
     amended by adding at the end the following new section:

[[Page 27325]]




    `` requirements and special rules for certain medicaid eligible 
                              individuals

       ``Sec. 1943.  (a) Coordination With NHI Exchange Through 
     Memorandum of Understanding.--
       ``(1) In general.--The State shall enter into a Medicaid 
     memorandum of understanding described in section 305(e)(2) of 
     the Affordable Health Care for America Act with the Health 
     Choices Commissioner, acting in consultation with the 
     Secretary, with respect to coordinating the implementation of 
     the provisions of division A of such Act with the State plan 
     under this title in order to ensure the enrollment of 
     Medicaid eligible individuals in acceptable coverage. Nothing 
     in this section shall be construed as permitting such 
     memorandum to modify or vitiate any requirement of a State 
     plan under this title.
       ``(2) Enrollment of exchange-referred individuals.--
       ``(A) Non-traditional individuals.--Pursuant to such 
     memorandum the State shall accept without further 
     determination the enrollment under this title of an 
     individual determined by the Commissioner to be a non-
     traditional Medicaid eligible individual. The State shall not 
     do any redeterminations of eligibility for such individuals 
     unless the periodicity of such redeterminations is consistent 
     with the periodicity for redeterminations by the Commissioner 
     of eligibility for affordability credits under subtitle C of 
     title II of division A of the Affordable Health Care for 
     America Act, as specified under such memorandum.
       ``(B) Traditional individuals.--Pursuant to such 
     memorandum, the State shall accept without further 
     determination the enrollment under this title of an 
     individual determined by the Commissioner to be a traditional 
     Medicaid eligible individual. The State may do 
     redeterminations of eligibility of such individual consistent 
     with such section and the memorandum.
       ``(3) Determinations of eligibility for affordability 
     credits.--If the Commissioner determines that a State 
     Medicaid agency has the capacity to make determinations of 
     eligibility for affordability credits under subtitle C of 
     title II of division A of the Affordable Health Care for 
     America Act, under such memorandum--
       ``(A) the State Medicaid agency shall conduct such 
     determinations for any Exchange-eligible individual who 
     requests such a determination;
       ``(B) in the case that a State Medicaid agency determines 
     that an Exchange-eligible individual is not eligible for 
     affordability credits, the agency shall forward the 
     information on the basis of which such determination was made 
     to the Commissioner; and
       ``(C) the Commissioner shall reimburse the State Medicaid 
     agency for the costs of conducting such determinations.
       ``(4) Referrals under memorandum.--Pursuant to such 
     memorandum, if an individual applies to the State for 
     assistance in obtaining health coverage and the State 
     determines that the individual is not eligible for medical 
     assistance under this title and is not authorized under such 
     memorandum to make an determination with respect to 
     eligibility for coverage and affordability credits through 
     the Health Insurance Exchange, the State shall refer the 
     individual to the Commissioner for a determination of such 
     eligibility and, with the individual's authorization, provide 
     to the Commissioner information obtained by the State as part 
     of the application process.
       ``(5) Additional terms.--Such memorandum shall include such 
     additional provisions as are necessary to implement 
     efficiently the provisions of this section and title II of 
     division A of the Affordable Health Care for America Act.
       ``(b) Treatment of Certain Newborns.--
       ``(1) In general.--In the case of a child who is deemed 
     under section 305(d) of the Affordable Health Care for 
     America Act to be a Medicaid eligible individual and enrolled 
     under this title pursuant to such section, the State shall 
     provide for a determination, by not later than the end of the 
     period referred to in paragraph (2) of such section, of the 
     child's eligibility for medical assistance under this title.
       ``(2) Extended treatment as traditional medicaid eligible 
     individual.--In accordance with paragraph (2) of section 
     305(d) of the Affordable Health Care for America Act, in the 
     case of a child described in paragraph (1) of such section 
     who at the end of the period referred to in such paragraph is 
     not otherwise covered under acceptable coverage, the child 
     shall be deemed (until such time as the child obtains such 
     coverage or the State otherwise makes a determination of the 
     child's eligibility for medical assistance under its plan 
     under this title pursuant to paragraph (1)) to be a Medicaid 
     eligible individual described in section 1902(l)(1)(B).
       ``(c) Definitions.--In this section:
       ``(1) Medicaid eligible individual.--The term `Medicaid 
     eligible individual' means an individual who is eligible for 
     medical assistance under Medicaid.
       ``(2) Traditional medicaid eligible individual.--The term 
     `traditional Medicaid eligible individual' means a Medicaid 
     eligible individual other than an individual who is--
       ``(A) a Medicaid eligible individual by reason of the 
     application of subclause (VIII) of section 1902(a)(10)(A)(i) 
     of the Social Security Act; or
       ``(B) a childless adult not described in section 
     1902(a)(10)(A) or (C) of such Act (as in effect as of the day 
     before the date of the enactment of this Act).
       ``(3) Non-traditional medicaid eligible individual.--The 
     term `non-traditional Medicaid eligible individual' means a 
     Medicaid eligible individual who is not a traditional 
     Medicaid eligible individual.
       ``(4) Memorandum.--The term `memorandum' means a Medicaid 
     memorandum of understanding under section 305(e)(2) of the 
     Affordable Health Care for America Act.
       ``(5) Y1.--The term `Y1' has the meaning given such term in 
     section 100(c) of the Affordable Health Care for America 
     Act.''.
       (b) Conforming Amendments to Error Rate.--
       (1) Section 1903(u)(1)(D) of the Social Security Act (42 
     U.S.C. 1396b(u)(1)(D)) is amended by adding at the end the 
     following new clause:
       ``(vi) In determining the amount of erroneous excess 
     payments, there shall not be included any erroneous payments 
     made that are attributable to an error in an eligibility 
     determination under subtitle C of title II of division A of 
     the Affordable Health Care for America Act.''.
       (2) Section 2105(c)(11) of such Act (42 U.S.C. 
     1397ee(c)(11)) is amended by adding at the end the following 
     new sentence: ``Clause (vi) of section 1903(u)(1)(D) shall 
     apply with respect to the application of such requirements 
     under this title and title XIX.''.

     SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGIBILITY.

       (a) CHIP Maintenance of Eligibility.--Section 1902 of the 
     Social Security Act (42 U.S.C. 1396a) is amended--
       (1) in subsection (a), as amended by section 
     1631(b)(1)(D)--
       (A) by striking ``and'' at the end of paragraph (73);
       (B) by striking the period at the end of paragraph (74) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (74) the following new 
     paragraph:
       ``(75) provide for maintenance of effort under the State 
     child health plan under title XXI in accordance with 
     subsection (gg).''; and
       (2) by adding at the end the following new subsection:
       ``(gg) CHIP Maintenance of Eligibility Requirement.--
       ``(1) In general.--Subject to paragraph (2), as a condition 
     of its State plan under this title under subsection (a)(75) 
     and receipt of any Federal financial assistance under section 
     1903(a) for calendar quarters beginning after the date of the 
     enactment of this subsection and before CHIP MOE termination 
     date specified in paragraph (3), a State shall not have in 
     effect eligibility standards, methodologies, or procedures 
     under its State child health plan under title XXI (including 
     any waiver under such title or demonstration project under 
     section 1115) that are more restrictive than the eligibility 
     standards, methodologies, or procedures, respectively, under 
     such plan (or waiver) as in effect on June 16, 2009.
       ``(2) Limitation.--Paragraph (1) shall not be construed as 
     preventing a State from imposing a limitation described in 
     section 2110(b)(5)(C)(i)(II) for a fiscal year in order to 
     limit expenditures under its State child health plan under 
     title XXI to those for which Federal financial participation 
     is available under section 2105 for the fiscal year.
       ``(3) CHIP moe termination date.--In paragraph (1), the 
     `CHIP MOE termination date' for a State is the date that is 
     the last day of Y1 (as defined in section 100(c) of the 
     Affordable Health Care for America Act).
       ``(4) CHIP transition report.--Not later than December 31, 
     2011, the Secretary shall submit to Congress a report--
       ``(A) that compares the benefits packages offered under an 
     average State child health plan under title XXI in 2011 and 
     to the benefit standards initially adopted under section 
     224(b) of the Affordable Health Care for America Act and for 
     affordability credits under subtitle C of title II of 
     division C of such Act; and
       ``(B) that includes such recommendations as may be 
     necessary to ensure that--
       ``(i) such coverage is at least comparable to the coverage 
     provided to children under such an average State child health 
     plan; and
       ``(ii) there are procedures in effect for the enrollment of 
     CHIP enrollees (including CHIP-eligible pregnant women) at 
     the end of Y1 under this title, into a qualified health 
     benefits plan offered through the Health Insurance Exchange, 
     or into other acceptable coverage (as defined for purposes of 
     such Act) without interruption of coverage or a written plan 
     of treatment.''.
       (b) Medicaid Maintenance of Effort; Simplifying and 
     Coordinating Eligibility Rules Between Exchange and 
     Medicaid.--
       (1) In general.--Section 1903 of such Act (42 U.S.C. 1396b) 
     is amended by adding at the end the following new subsection:
       ``(aa) Maintenance of Medicaid Effort; Simplifying and 
     Coordinating Eligibility Rules Between Health Insurance 
     Exchange and Medicaid.--
       ``(1) Maintenance of effort.--
       ``(A) In general.--Subject to subparagraph (B), a State is 
     not eligible for payment under

[[Page 27326]]

     subsection (a) for a calendar quarter beginning after the 
     date of the enactment of this subsection if eligibility 
     standards, methodologies, or procedures under its plan under 
     this title (including any waiver under this title or 
     demonstration project under section 1115) that are more 
     restrictive than the eligibility standards, methodologies, or 
     procedures, respectively, under such plan (or waiver) as in 
     effect on June 16, 2009. The Secretary shall extend such a 
     waiver (including the availability of Federal financial 
     participation under such waiver) for such period as may be 
     required for a State to meet the requirement of the previous 
     sentence.
       ``(B) Exception for certain demonstration projects.--In the 
     case of a State demonstration project under section 1115 in 
     effect on June 16, 2009, that permits individuals to be 
     eligible solely to receive a premium or cost-sharing subsidy 
     for individual or group health insurance coverage, effective 
     for coverage provided in Y1--
       ``(i) the Secretary shall permit the State to amend such 
     waiver to apply more restrictive eligibility standards, 
     methodologies, or procedures with respect to such individuals 
     under such waiver; and
       ``(ii) the application of such more restrictive, standards, 
     methodologies, or procedures under such an amendment shall 
     not be considered in violation of the requirement of 
     subparagraph (A).
       ``(2) Removal of asset test for certain eligibility 
     categories.--
       ``(A) In general.--A State is not eligible for payment 
     under subsection (a) for a calendar quarter beginning on or 
     after the first day of Y1 (as defined in section 100(c) of 
     the Affordable Health Care for America Act), if the State 
     applies any asset or resource test in determining (or 
     redetermining) eligibility of any individual on or after such 
     first day under any of the following:
       ``(i) Subclause (I), (III), (IV), (VI), (VIII), (IX), (X), 
     or (XI) of section 1902(a)(10)(A)(i).
       ``(ii) Subclause (II), (IX), (XIV) or (XVII) of section 
     1902(a)(10)(A)(ii).
       ``(iii) Section 1931(b).
       ``(B) Overriding contrary provisions; references.--The 
     provisions of this title that prevent the waiver of an asset 
     or resource test described in subparagraph (A) are hereby 
     waived.
       ``(C) References.--Any reference to a provision described 
     in a provision in subparagraph (A) shall be deemed to be a 
     reference to such provision as modified through the 
     application of subparagraphs (A) and (B).''.
       (2) Conforming amendments.--(A) Section 1902(a)(10)(A) of 
     such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the 
     matter before clause (i), by inserting ``subject to section 
     1903(aa)(2),'' after ``(A)''.
       (B) Section 1931(b)(1) of such Act (42 U.S.C. 1396u-
     1(b)(1)) is amended by inserting ``and section 1903(aa)(2)'' 
     after ``and (3)''.
       (c) Standards for Benchmark Packages.--Section 1937(b) of 
     such Act (42 U.S.C. 1396u-7(b)) is amended--
       (1) in each of paragraphs (1) and (2), by inserting 
     ``subject to paragraph (5),'' after ``subsection (a)(1),''; 
     and
       (2) by adding at the end the following new paragraph:
       ``(5) Minimum standards.--Effective January 1, 2013, any 
     benchmark benefit package (or benchmark equivalent coverage 
     under paragraph (2)) must meet the minimum benefits and cost-
     sharing standards of a basic plan offered through the Health 
     Insurance Exchange.''.
       (d) Repeal of CHIP.--Section 2104(a) of the Social Security 
     Act is amended by inserting at the end the following:
     ``No funds shall be appropriated or authorized to be 
     appropriated under this section for fiscal year 2014 and 
     subsequent years.''.

     SEC. 1704. REDUCTION IN MEDICAID DSH.

       (a) Report.--
       (1) In general.--Not later than January 1, 2016, the 
     Secretary of Health and Human Services (in this title 
     referred to as the ``Secretary'') shall submit to Congress a 
     report concerning the extent to which, based upon the impact 
     of the health care reforms carried out under division A in 
     reducing the number of uninsured individuals, there is a 
     continued role for Medicaid DSH. In preparing the report, the 
     Secretary shall consult with community-based health care 
     networks serving low-income beneficiaries.
       (2) Matters to be included.--The report shall include the 
     following:
       (A) Recommendations.--Recommendations regarding--
       (i) the appropriate targeting of Medicaid DSH within 
     States; and
       (ii) the distribution of Medicaid DSH among the States, 
     taking into account the ratio of the amount of DSH funds 
     allocated to a State to the number of uninsured individuals 
     in such State.
       (B) Specification of dsh health reform methodology.--The 
     DSH Health Reform methodology described in paragraph (2) of 
     subsection (b) for purposes of implementing the requirements 
     of such subsection.
       (3) Coordination with medicare dsh report.--The Secretary 
     shall coordinate the report under this subsection with the 
     report on Medicare DSH under section 1112.
       (4) Medicaid dsh.--In this section, the term ``Medicaid 
     DSH'' means adjustments in payments under section 1923 of the 
     Social Security Act for inpatient hospital services furnished 
     by disproportionate share hospitals.
       (b) Medicaid DSH Reductions.--
       (1) Reductions.--
       (A) In general.--For each of fiscal years 2017 through 2019 
     the Secretary shall effect the following reductions:
       (i) Reduction dsh allotments.--The Secretary shall reduce 
     DSH allotments to States in the amount specified under the 
     DSH health reform methodology under paragraph (2) for the 
     State for the fiscal year.
       (ii) Reductions in payments.--The Secretary shall reduce 
     payments to States under section 1903(a) of the Social 
     Security Act (42 U.S.C. 1396b(a)) for each calendar quarter 
     in the fiscal year, in the manner specified in subparagraph 
     (C), in an amount equal to \1/4\ of the DSH allotment 
     reduction under clause (i) for the State for the fiscal year.
       (B) Aggregate reductions.--The aggregate reductions in DSH 
     allotments for all States under subparagraph (A)(i) shall be 
     equal to--
       (i) $1,500,000,000 for fiscal year 2017;
       (ii) $2,500,000,000 for fiscal year 2018; and
       (iii) $6,000,000,000 for fiscal year 2019.
     The Secretary shall distribute such aggregate reduction among 
     States in accordance with paragraph (2).
       (C) Manner of payment reduction.--The amount of the payment 
     reduction under subparagraph (A)(ii) for a State for a 
     quarter shall be deemed an overpayment to the State under 
     title XIX of the Social Security Act to be disallowed against 
     the State's regular quarterly draw for all Medicaid spending 
     under section 1903(d)(2) of such Act (42 U.S.C. 1396b(d)(2)). 
     Such a disallowance is not subject to a reconsideration under 
     1116(d) of such Act (42 U.S.C. 1316(d)).
       (D) Definitions.--In this section:
       (i) State.--The term ``State'' means the 50 States and the 
     District of Columbia.
       (ii) DSH allotment.--The term ``DSH allotment'' means, with 
     respect to a State for a fiscal year, the allotment made 
     under section 1923(f) of the Social Security Act (42 U.S.C. 
     1396r-4(f)) to the State for the fiscal year.
       (2) DSH health reform methodology.--The Secretary shall 
     carry out paragraph (1) through use of a DSH Health Reform 
     methodology issued by the Secretary that imposes the largest 
     percentage reductions on the States that--
       (A) have the lowest percentages of uninsured individuals 
     (determined on the basis of audited hospital cost reports) 
     during the most recent year for which such data are 
     available; or
       (B) do not target their DSH payments on--
       (i) hospitals with high volumes of Medicaid inpatients (as 
     defined in section 1923(b)(1)(A) of the Social Security Act 
     (42 U.S.C. 1396r-4(b)(1)(A)); and
       (ii) hospitals that have high levels of uncompensated care 
     (excluding bad debt).
       (3) DSH allotment publications.--
       (A) In general.--Not later than the publication deadline 
     specified in subparagraph (B), the Secretary shall publish in 
     the Federal Register a notice specifying the DSH allotment to 
     each State under 1923(f) of the Social Security Act for the 
     respective fiscal year specified in such subparagraph, 
     consistent with the application of the DSH Health Reform 
     methodology described in paragraph (2).
       (B) Publication deadline.--The publication deadline 
     specified in this subparagraph is--
       (i) January 1, 2016, with respect to DSH allotments 
     described in subparagraph (A) for fiscal year 2017;
       (ii) January 1, 2017, with respect to DSH allotments 
     described in subparagraph (A) for fiscal year 2018; and
       (iii) January 1, 2018, with respect to DSH allotments 
     described in subparagraph (A) for fiscal year 2019.
       (c) Conforming Amendments.--
       (1) Section 1923(f) of the Social Security Act (42 U.S.C. 
     1396r-4(f)) is amended--
       (A) by redesignating paragraph (7) as paragraph (8); and
       (B) by inserting after paragraph (6) the following new 
     paragraph:
       ``(7) Special rule for fiscal years 2017, 2018, and 2019.--
     For each of fiscal years 2017, 2018, and 2018, the DSH 
     allotments under this subsection are subject to reduction 
     under section 1704(b) of the Affordable Health Care for 
     America Act.''.
       (2) The second sentence of section 1923(b)(4) of such Act 
     (42 U.S.C. 1396r-4(b)(4)) is amended by inserting before the 
     period the following: ``or to affect the authority of the 
     Secretary to issue and implement the DSH Health Reform 
     methodology under section 1704(b)(2) of the Affordable Health 
     Care for America Act''.
       (d) Disproportionate Share Hospitals (DSH) and Essential 
     Access Hospital (EAH) Non-discrimination.--
       (1) In general.--Section 1923(d) of the Social Security Act 
     (42 U.S.C. 1396r-4) is amended by adding at the end the 
     following new paragraph:
       ``(4) No hospital may be defined or deemed as a 
     disproportionate share hospital, or as an essential access 
     hospital (for purposes of subsection (f)(6)(A)(iv)), under a 
     State plan under this title or subsection (b) of this section 
     (including any demonstration project under section 1115) 
     unless the hospital--

[[Page 27327]]

       ``(A) provides services to beneficiaries under this title 
     without discrimination on the ground of race, color, national 
     origin, creed, source of payment, status as a beneficiary 
     under this title, or any other ground unrelated to such 
     beneficiary's need for the services or the availability of 
     the needed services in the hospital; and
       ``(B) makes arrangements for, and accepts, reimbursement 
     under this title for services provided to eligible 
     beneficiaries under this title.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to expenditures made on or after July 1, 2010.

     SEC. 1705. EXPANDED OUTSTATIONING.

       (a) In General.--Section 1902(a)(55) of the Social Security 
     Act (42 U.S.C. 1396a(a)(55)) is amended by striking ``under 
     subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), 
     (a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)'' and inserting 
     ``(including receipt and processing of applications of 
     individuals for affordability credits under subtitle C of 
     title II of division A of the Affordable Health Care for 
     America Act pursuant to a Medicaid memorandum of 
     understanding under section 1943(a)(1))''.
       (b) Effective Date.--Except as provided in section 1790, 
     the amendment made by subsection (a) shall apply to services 
     furnished on or after July 1, 2010, without regard to whether 
     or not final regulations to carry out such amendment have 
     been promulgated by such date.

                         Subtitle B--Prevention

     SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES.

       (a) Coverage.--Section 1905 of the Social Security Act (42 
     U.S.C. 1396d), as amended by section 1701(a)(3)(B), is 
     amended--
       (1) in subsection (a)(4)--
       (A) by striking ``and'' before ``(C)''; and
       (B) by inserting before the semicolon at the end the 
     following: ``; and (D) preventive services described in 
     subsection (z)''; and
       (2) by adding at the end the following new subsection:
       ``(z) Preventive Services.--The preventive services 
     described in this subsection are services not otherwise 
     described in subsection (a) or (r) that the Secretary 
     determines are--
       ``(1)(A) recommended with a grade of A or B by the Task 
     Force for Clinical Preventive Services; or
       ``(B) vaccines recommended for use as appropriate by the 
     Director of the Centers for Disease Control and Prevention; 
     and
       ``(2) appropriate for individuals entitled to medical 
     assistance under this title.''.
       (b) Elimination of Cost-Sharing.--
       (1) Subsections (a)(2)(D) and (b)(2)(D) of section 1916 of 
     such Act (42 U.S.C. 1396o) are each amended by inserting 
     ``preventive services described in section 1905(z),'' after 
     ``emergency services (as defined by the Secretary),''.
       (2) Section 1916A(a)(1) of such Act (42 U.S.C. 1396o-1 
     (a)(1)) is amended by inserting ``, preventive services 
     described in section 1905(z),'' after ``subsection (c)''.
       (c) Conforming Amendment.--Section 1928 of such Act (42 
     U.S.C. 1396s) is amended--
       (1) in subsection (c)(2)(B)(i), by striking ``the advisory 
     committee referred to in subsection (e)'' and inserting ``the 
     Director of the Centers for Disease Control and Prevention'';
       (2) in subsection (e), by striking ``Advisory Committee'' 
     and all that follows and inserting ``Director of the Centers 
     for Disease Control and Prevention.''; and
       (3) by striking subsection (g).
       (d) Effective Date.--Except as provided in section 1790, 
     the amendments made by this section shall apply to services 
     furnished on or after July 1, 2010, without regard to whether 
     or not final regulations to carry out such amendments have 
     been promulgated by such date.

     SEC. 1712. TOBACCO CESSATION.

       (a) Dropping Tobacco Cessation Exclusion From Covered 
     Outpatient Drugs.--Section 1927(d)(2) of the Social Security 
     Act (42 U.S.C. 1396r-8(d)(2)) is amended--
       (1) by striking subparagraph (E);
       (2) in subparagraph (G), by inserting before the period at 
     the end the following: ``, except agents approved by the Food 
     and Drug Administration for purposes of promoting, and when 
     used to promote, tobacco cessation''; and
       (3) by redesignating subparagraphs (F) through (K) as 
     subparagraphs (E) through (J), respectively.
       (b) Effective Date.--The amendments made by this section 
     shall apply to drugs and services furnished on or after 
     January 1, 2010.

     SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITATION 
                   SERVICES.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d), as amended by sections 1701(a)(3)(B) and 
     1711(a), is amended--
       (1) in subsection (a)--
       (A) in paragraph (27), by striking ``and'' at the end;
       (B) by redesignating paragraph (28) as paragraph (29); and
       (C) by inserting after paragraph (27) the following new 
     paragraph:
       ``(28) nurse home visitation services (as defined in 
     subsection (aa)); and''; and
       (2) by adding at the end the following new subsection:
       ``(aa) The term `nurse home visitation services' means home 
     visits by trained nurses to families with a first-time 
     pregnant woman, or a child (under 2 years of age), who is 
     eligible for medical assistance under this title, but only, 
     to the extent determined by the Secretary based upon 
     evidence, that such services are effective in one or more of 
     the following:
       ``(1) Improving maternal or child health and pregnancy 
     outcomes or increasing birth intervals between pregnancies.
       ``(2) Reducing the incidence of child abuse, neglect, and 
     injury, improving family stability (including reduction in 
     the incidence of intimate partner violence), or reducing 
     maternal and child involvement in the criminal justice 
     system.
       ``(3) Increasing economic self-sufficiency, employment 
     advancement, school-readiness, and educational achievement, 
     or reducing dependence on public assistance.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2010.
       (c) Construction.--Nothing in the amendments made by this 
     section shall be construed as affecting the ability of a 
     State under title XIX or XXI of the Social Security Act to 
     provide nurse home visitation services as part of another 
     class of items and services falling within the definition of 
     medical assistance or child health assistance under the 
     respective title, or as an administrative expenditure for 
     which payment is made under section 1903(a) or 2105(a) of 
     such Act, respectively, on or after the date of the enactment 
     of this Act.

     SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING 
                   SERVICES.

       (a) Coverage as Optional Categorically Needy Group.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
       (A) in subclause (XVIII), by striking ``or'' at the end;
       (B) in subclause (XIX), by adding ``or'' at the end; and
       (C) by adding at the end the following new subclause:

       ``(XX) who are described in subsection (hh) (relating to 
     individuals who meet certain income standards);''.

       (2) Group described.--Section 1902 of such Act (42 U.S.C. 
     1396a), as amended by section 1703, is amended by adding at 
     the end the following new subsection:
       ``(hh)(1) Individuals described in this subsection are 
     individuals--
       ``(A) whose income does not exceed an income eligibility 
     level established by the State that does not exceed the 
     highest income eligibility level established under the State 
     plan under this title (or under its State child health plan 
     under title XXI) for pregnant women; and
       ``(B) who are not pregnant.
       ``(2) At the option of a State, individuals described in 
     this subsection may include individuals who, had individuals 
     applied on or before January 1, 2007, would have been made 
     eligible pursuant to the standards and processes imposed by 
     that State for benefits described in clause (XV) of the 
     matter following subparagraph (G) of subsection (a)(10) 
     pursuant to a demonstration project waiver granted under 
     section 1115.
       ``(3) At the option of a State, for purposes of subsection 
     (a)(17)(B), in determining eligibility for services under 
     this subsection, the State may consider only the income of 
     the applicant or recipient.''.
       (3) Limitation on benefits.--Section 1902(a)(10) of such 
     Act (42 U.S.C. 1396a(a)(10)) is amended in the matter 
     following subparagraph (G)--
       (A) by striking ``and (XIV)'' and inserting ``(XIV)''; and
       (B) by inserting ``, and (XV) the medical assistance made 
     available to an individual described in subsection (hh) shall 
     be limited to family planning services and supplies described 
     in section 1905(a)(4)(C) including medical diagnosis and 
     treatment services that are provided pursuant to a family 
     planning service in a family planning setting'' after 
     ``cervical cancer''.
       (4) Conforming amendments.--Section 1905(a) of such Act (42 
     U.S.C. 1396d(a)), as amended by section 1731(c), is amended 
     in the matter preceding paragraph (1)--
       (A) in clause (xiii), by striking ``or'' at the end;
       (B) in clause (xiv), by adding ``or'' at the end; and
       (C) by inserting after clause (xiv) the following:
       ``(xv) individuals described in section 1902(hh),''.
       (b) Presumptive Eligibility.--
       (1) In general.--Title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.) is amended by inserting after section 
     1920B the following:


         ``presumptive eligibility for family planning services

       ``Sec. 1920C.  (a) State Option.--State plan approved under 
     section 1902 may provide for making medical assistance 
     available to an individual described in section 1902(hh) 
     (relating to individuals who meet certain income eligibility 
     standard) during a presumptive eligibility period. In the 
     case of an individual described in section 1902(hh), such 
     medical assistance shall be limited to family planning 
     services and supplies described in 1905(a)(4)(C) and, at the 
     State's option, medical diagnosis and treatment services that

[[Page 27328]]

     are provided in conjunction with a family planning service in 
     a family planning setting.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Presumptive eligibility period.--The term 
     `presumptive eligibility period' means, with respect to an 
     individual described in subsection (a), the period that--
       ``(A) begins with the date on which a qualified entity 
     determines, on the basis of preliminary information, that the 
     individual is described in section 1902(hh); and
       ``(B) ends with (and includes) the earlier of--
       ``(i) the day on which a determination is made with respect 
     to the eligibility of such individual for services under the 
     State plan; or
       ``(ii) in the case of such an individual who does not file 
     an application by the last day of the month following the 
     month during which the entity makes the determination 
     referred to in subparagraph (A), such last day.
       ``(2) Qualified entity.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `qualified entity' means any entity that--
       ``(i) is eligible for payments under a State plan approved 
     under this title; and
       ``(ii) is determined by the State agency to be capable of 
     making determinations of the type described in paragraph 
     (1)(A).
       ``(B) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a State from limiting the 
     classes of entities that may become qualified entities in 
     order to prevent fraud and abuse.
       ``(c) Administration.--
       ``(1) In general.--The State agency shall provide qualified 
     entities with--
       ``(A) such forms as are necessary for an application to be 
     made by an individual described in subsection (a) for medical 
     assistance under the State plan; and
       ``(B) information on how to assist such individuals in 
     completing and filing such forms.
       ``(2) Notification requirements.--A qualified entity that 
     determines under subsection (b)(1)(A) that an individual 
     described in subsection (a) is presumptively eligible for 
     medical assistance under a State plan shall--
       ``(A) notify the State agency of the determination within 5 
     working days after the date on which determination is made; 
     and
       ``(B) inform such individual at the time the determination 
     is made that an application for medical assistance is 
     required to be made by not later than the last day of the 
     month following the month during which the determination is 
     made.
       ``(3) Application for medical assistance.--In the case of 
     an individual described in subsection (a) who is determined 
     by a qualified entity to be presumptively eligible for 
     medical assistance under a State plan, the individual shall 
     apply for medical assistance by not later than the last day 
     of the month following the month during which the 
     determination is made.
       ``(d) Payment.--Notwithstanding any other provision of law, 
     medical assistance that--
       ``(1) is furnished to an individual described in subsection 
     (a)--
       ``(A) during a presumptive eligibility period;
       ``(B) by a entity that is eligible for payments under the 
     State plan; and
       ``(2) is included in the care and services covered by the 
     State plan,

     shall be treated as medical assistance provided by such plan 
     for purposes of clause (4) of the first sentence of section 
     1905(b).''.
       (2) Conforming amendments.--
       (A) Section 1902(a)(47) of the Social Security Act (42 
     U.S.C. 1396a(a)(47)) is amended by inserting before the 
     semicolon at the end the following: ``and provide for making 
     medical assistance available to individuals described in 
     subsection (a) of section 1920C during a presumptive 
     eligibility period in accordance with such section''.
       (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
     1396b(u)(1)(D)(v)) is amended--
       (i) by striking ``or for'' and inserting ``for''; and
       (ii) by inserting before the period the following: ``, or 
     for medical assistance provided to an individual described in 
     subsection (a) of section 1920C during a presumptive 
     eligibility period under such section''.
       (c) Clarification of Coverage of Family Planning Services 
     and Supplies.--Section 1937(b) of the Social Security Act (42 
     U.S.C. 1396u-7(b)), as amended by section 1703(c)(2), is 
     amended by adding at the end the following:
       ``(6) Coverage of family planning services and supplies.--
     Notwithstanding the previous provisions of this section, a 
     State may not provide for medical assistance through 
     enrollment of an individual with benchmark coverage or 
     benchmark-equivalent coverage under this section unless such 
     coverage includes for any individual described in section 
     1905(a)(4)(C), medical assistance for family planning 
     services and supplies in accordance with such section.''.
       (d) Effective Date.--The amendments made by this section 
     take effect on the date of the enactment of this Act and 
     shall apply to items and services furnished on or after such 
     date.

                           Subtitle C--Access

     SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.

       (a) In General.--
       (1) Fee-for-service payments.--Section 1902 of the Social 
     Security Act (42 U.S.C. 1396b) as amended by sections 
     1703(a), 1714(a), 1731(a), and 1746, is amended--
       (A) in subsection (a)(13)--
       (i) by striking ``and'' at the end of subparagraph (A);
       (ii) by adding ``and'' at the end of subparagraph (B); and
       (iii) by adding at the end the following new subparagraph:
       ``(C) payment for primary care services (as defined in 
     subsection (kk)(1)) furnished by physicians (or for services 
     furnished by other health care professionals that would be 
     primary care services under such section if furnished by a 
     physician) at a rate not less than 80 percent of the payment 
     rate that would be applicable if the adjustment described in 
     subsection (kk)(2) were to apply to such services and 
     physicians or professionals (as the case may be) under part B 
     of title XVIII for services furnished in 2010, 90 percent of 
     such adjusted payment rate for services and physicians (or 
     professionals) furnished in 2011, or 100 percent of such 
     adjusted payment rate for services and physicians (or 
     professionals) furnished in 2012 and each subsequent year;''; 
     and
       (B) by adding at the end the following new subsection:
       ``(kk) Increased Payment for Primary Care Services.--For 
     purposes of subsection (a)(13)(C):
       ``(1) Primary care services defined.--The term `primary 
     care services' means evaluation and management services, 
     without regard to the specialty of the physician furnishing 
     the services, that are procedure codes (for services covered 
     under title XVIII) for services in the category designated 
     Evaluation and Management in the Health Care Common Procedure 
     Coding System (established by the Secretary under section 
     1848(c)(5) as of December 31, 2009, and as subsequently 
     modified by the Secretary).
       ``(2) Adjustment.--The adjustment described in this 
     paragraph is the substitution of 1.25 percent for the update 
     otherwise provided under section 1848(d)(4) for each year 
     beginning with 2010.''.
       (2) Under medicaid managed care plans.--Section 1932(f) of 
     such Act (42 U.S.C. 1396u-2(f)) is amended--
       (A) in the heading, by adding at the end the following: ``; 
     Adequacy of Payment for Primary Care Services''; and
       (B) by inserting before the period at the end the 
     following: ``and, in the case of primary care services 
     described in section 1902(a)(13)(C), consistent with the 
     minimum payment rates specified in such section (regardless 
     of the manner in which such payments are made, including in 
     the form of capitation or partial capitation)''.
       (b) Increase in Payment Using Increased FMAP.--Section 
     1905(y) of the Social Security Act, as added by section 
     1701(a)(3)(B) and as amended by section 1701(c)(2), is 
     amended by adding at the end the following:
       ``(3)(A) The portion of the amounts expended for medical 
     assistance for services described in section 1902(a)(13)(C) 
     furnished on or after January 1, 2010, that is attributable 
     to the amount by which the minimum payment rate required 
     under such section (or, by application, section 1932(f)) 
     exceeds the payment rate applicable to such services under 
     the State plan as of June 16, 2009.
       ``(B) Subparagraph (A) shall not be construed as preventing 
     the payment of Federal financial participation based on the 
     Federal medical assistance percentage for amounts in excess 
     of those specified under such subparagraph.''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2010.

     SEC. 1722. MEDICAL HOME PILOT PROGRAM.

       (a) In General.--The Secretary of Health and Human Services 
     shall establish under this section a medical home pilot 
     program under which a State may apply to the Secretary for 
     approval of a medical home pilot project described in 
     subsection (b) (in this section referred to as a ``pilot 
     project'') for the application of the medical home concept 
     under title XIX of the Social Security Act. The pilot program 
     shall operate for a period of up to 5 years.
       (b) Pilot Project Described.--
       (1) In general.--A pilot project is a project that applies 
     one or more of the medical home models described in section 
     1866F(a)(3) of the Social Security Act (as inserted by 
     section 1302(a)) or such other model as the Secretary may 
     approve, to individuals (including medically fragile children 
     and high-risk pregnant women) who are eligible for medical 
     assistance under title XIX of the Social Security Act. The 
     Secretary shall provide for appropriate coordination of the 
     pilot program under this section with the medical home pilot 
     program under section 1866F of such Act.
       (2) Limitation.--A pilot project shall be for a duration of 
     not more than 5 years.
       (3) Consideration for certain technologies.--In considering 
     applications for pilots projects under this section, the 
     Secretary may approve a project which tests the effectiveness 
     of applications and devices, such as wireless patient 
     management technologies, that are approved by the Food and

[[Page 27329]]

     Drug Administration and enable providers and practitioners to 
     communicate directly with their patients in managing chronic 
     illness.
       (c) Additional Incentives.--In the case of a pilot project, 
     the Secretary may--
       (1) waive the requirements of section 1902(a)(1) of the 
     Social Security Act (relating to statewideness) and section 
     1902(a)(10)(B) of such Act (relating to comparability); and
       (2) increase to up to 90 percent (for the first 2 years of 
     the pilot program) or 75 percent (for the next 3 years) the 
     matching percentage for administrative expenditures (such as 
     those for community care workers).
       (d) Medically Fragile Children.--In the case of a model 
     involving medically fragile children, the model shall ensure 
     that the patient-centered medical home services received by 
     each child, in addition to fulfilling the requirements under 
     1866F(b)(1) of the Social Security Act, provide for 
     continuous involvement and education of the parent or 
     caregiver and for assistance to the child in obtaining 
     necessary transitional care if a child's enrollment ceases 
     for any reason.
       (e) Evaluation; Report.--
       (1) Evaluation.--The Secretary, using the criteria 
     described in section 1866F(e)(1) of the Social Security Act 
     (as inserted by section 1123), shall conduct an evaluation of 
     the pilot program under this section.
       (2) Report.--Not later than 60 days after the date of 
     completion of the evaluation under paragraph (1), the 
     Secretary shall submit to Congress and make available to the 
     public a report on the findings of the evaluation under such 
     paragraph.
       (f) Funding.--The additional Federal financial 
     participation resulting from the implementation of the pilot 
     program under this section may not exceed in the aggregate 
     $1,235,000,000 over the 5-year period of the program.

     SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES.

       (a) In General.--Section 1903(a)(2)(E) of the Social 
     Security Act (42 U.S.C. 1396b(a)(2)), as added by section 
     201(b)(2)(A) of the Children's Health Insurance Program 
     Reauthorization Act of 2009 (Public Law 111-3), is amended by 
     inserting ``and other individuals'' after ``children of 
     families''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to payment for translation or interpretation 
     services furnished on or after January 1, 2010.

     SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER 
                   SERVICES.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d), as amended by section 1713(a), is 
     amended--
       (1) in subsection (a)--
       (A) by redesignating paragraph (29) as paragraph (30);
       (B) in paragraph (28), by striking at the end ``and''; and
       (C) by inserting after paragraph (28) the following new 
     paragraph:
       ``(29) freestanding birth center services (as defined in 
     subsection (l)(3)(A)) and other ambulatory services that are 
     offered by a freestanding birth center (as defined in 
     subsection (l)(3)(B)) and that are otherwise included in the 
     plan; and''; and
       (2) in subsection (l), by adding at the end the following 
     new paragraph:
       ``(3)(A) The term `freestanding birth center services' 
     means services furnished to an individual at a freestanding 
     birth center (as defined in subparagraph (B)), including by a 
     licensed birth attendant (as defined in subparagraph (C)) at 
     such center.
       ``(B) The term `freestanding birth center' means a health 
     facility--
       ``(i) that is not a hospital; and
       ``(ii) where childbirth is planned to occur away from the 
     pregnant woman's residence.
       ``(C) The term `licensed birth attendant' means an 
     individual who is licensed or registered by the State 
     involved to provide health care at childbirth and who 
     provides such care within the scope of practice under which 
     the individual is legally authorized to perform such care 
     under State law (or the State regulatory mechanism provided 
     by State law), regardless of whether the individual is under 
     the supervision of, or associated with, a physician or other 
     health care provider. Nothing in this subparagraph shall be 
     construed as changing State law requirements applicable to a 
     licensed birth attendant.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to items and services furnished on or after the 
     date of the enactment of this Act.

     SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE 
                   VACCINES FOR CHILDREN PROGRAM.

       Section 1928(b)(2)(A)(iii)(I) of the Social Security Act 
     (42 U.S.C. 1396s(b)(2)(A)(iii)(I)) is amended--
       (1) by striking ``or a rural health clinic'' and inserting 
     ``, a rural health clinic''; and
       (2) by inserting ``or a public health clinic,'' after 
     ``1905(l)(1)),''.

     SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIATRISTS.

       (a) In General.--Section 1905(a)(5)(A) of the Social 
     Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended by 
     striking ``section 1861(r)(1)'' and inserting ``paragraphs 
     (1) and (3) of section 1861(r)''.
       (b) Effective Date.--Except as provided in section 1790, 
     the amendment made by subsection (a) shall apply to services 
     furnished on or after January 1, 2010.

     SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OPTOMETRISTS.

       (a) In General.--Section 1905(a)(5) of the Social Security 
     Act (42 U.S.C. 1396d(a)(5)) is amended--
       (1) by striking ``and'' before ``(B)''; and
       (2) by inserting before the semicolon at the end the 
     following: ``, and (C) medical and other health services (as 
     defined in section 1861(s)) as authorized by State law, 
     furnished by an optometrist (described in section 1861(r)(4)) 
     to the extent such services may be performed under State 
     law''.
       (b) Effective Date.--Except as provided in section 1790, 
     the amendments made by subsection (a) shall take effect 90 
     days after the date of the enactment of this Act and shall 
     apply to services furnished or other actions required on or 
     after such date.

     SEC. 1727. THERAPEUTIC FOSTER CARE.

       (a) Rule of Construction.--Nothing in this title shall 
     prevent or limit a State from covering therapeutic foster 
     care for eligible children in out-of-home placements under 
     section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)).
       (b) Therapeutic Foster Care Defined.--For purposes of this 
     section, the term ``therapeutic foster care'' means a foster 
     care program that provides--
       (1) to the child--
       (A) structured daily activities that develop, improve, 
     monitor, and reinforce age-appropriate social, 
     communications, and behavioral skills;
       (B) crisis intervention and crisis support services;
       (C) medication monitoring;
       (D) counseling; and
       (E) case management services; and
       (2) specialized training for the foster parent and 
     consultation with the foster parent on the management of 
     children with mental illnesses and related health and 
     developmental conditions.

     SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES.

       (a) In General.--Title XIX of the Social Security Act is 
     amended by inserting after section 1925 the following new 
     section:


            ``assuring adequate payment levels for services

       ``Sec. 1926.  (a) In General.--A State plan under this 
     title shall not be considered to meet the requirement of 
     section 1902(a)(30)(A) for a year (beginning with 2011) 
     unless, by not later than April 1 before the beginning of 
     such year, the State submits to the Secretary an amendment to 
     the plan that specifies the payment rates to be used for such 
     services under the plan in such year and includes in such 
     submission such additional data as will assist the Secretary 
     in evaluating the State's compliance with such requirement, 
     including data relating to how rates established for payments 
     to medicaid managed care organizations under sections 1903(m) 
     and 1932 take into account such payment rates.
       ``(b) Secretarial Review.--The Secretary, by not later than 
     90 days after the date of submission of a plan amendment 
     under subsection (a), shall--
       ``(1) review each such amendment for compliance with the 
     requirement of section 1902(a)(30)(A); and
       ``(2) approve or disapprove each such amendment.

     If the Secretary disapproves such an amendment, the State 
     shall immediately submit a revised amendment that meets such 
     requirement.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall take effect on the date of the enactment of this Act.

     SEC. 1729. PRESERVING MEDICAID COVERAGE FOR YOUTHS UPON 
                   RELEASE FROM PUBLIC INSTITUTIONS.

       Section 1902(a) of the Social Security Act (42 U.S.C. 
     1396a), as amended by section 1631(b) and 1703(a), is 
     amended--
       (1) by striking ``and'' at the end of paragraph (74);
       (2) by striking the period at the end of paragraph (75) and 
     inserting ``; and''; and
       (3) by inserting after paragraph (75) the following new 
     paragraph:
       ``(76) provide that in the case of any youth who is 18 
     years of age or younger, was enrolled for medical assistance 
     under the State plan immediately before becoming an inmate of 
     a public institution, is 18 years of age or younger upon 
     release from such institution, and is eligible for such 
     medical assistance under the State plan at the time of 
     release from such institution--
       ``(A) during the period such youth is incarcerated in a 
     public institution, the State shall not terminate eligibility 
     for medical assistance under the State plan for such youth;
       ``(B) during the period such youth is incarcerated in a 
     public institution, the State shall establish a process that 
     ensures--
       ``(i) that the State does not claim federal financial 
     participation for services that are provided to such youth 
     and that are excluded under subsection 1905(a)(28)(A); and
       ``(ii) that the youth receives medical assistance for which 
     federal participation is available under this title;
       ``(C) on or before the date such youth is released from 
     such institution, the State shall

[[Page 27330]]

     ensure that such youth is enrolled for medical assistance 
     under this title, unless and until there is a determination 
     that the individual is no longer eligible to be so enrolled; 
     and
       ``(D) the State shall ensure that enrollment under 
     subparagraph (C) will be completed before such date so that 
     the youth can access medical assistance under this title 
     immediately upon leaving the institution.''

     SEC. 1730. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH 
                   SERVICES UNDER MEDICAID AND CHIP.

       Title XI of the Social Security Act (42 U.S.C. 1301 et 
     seq.) is amended by inserting after section 1139A the 
     following new section:

     ``SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH 
                   SERVICES UNDER MEDICAID AND CHIP.

       ``(a) Maternity Care Quality Measures Under Medicaid and 
     CHIP.--
       ``(1) Development of measures.--No later than January 1, 
     2011, the Secretary shall develop and publish for comment a 
     proposed set of measures that accurately describe the quality 
     of maternity care provided under State plans under titles XIX 
     and XXI. The Secretary shall publish a final recommended set 
     of such measures no later than July 1, 2011.
       ``(2) Standardized reporting format.--No later than January 
     1, 2012, the Secretary shall develop and publish a 
     standardized reporting format for maternity care quality 
     measures for use by State programs under titles XIX and XXI 
     to collect data from managed care entities and providers and 
     practitioners that participate in such programs and to report 
     maternity care quality measures to the Secretary.
       ``(b) Other Adult Health Quality Measures Under Medicaid.--
       ``(1) Development of measures.--The Secretary shall develop 
     quality measures that are not otherwise developed under 
     section 1192 for services received under State plans under 
     title XIX by individuals who are 21 years of age or older but 
     have not attained age 65. The Secretary shall publish such 
     quality measures through notice and comment rulemaking.
       ``(2) Standardized reporting format.--The Secretary shall 
     develop and publish a standardized reporting format for 
     quality measures developed under paragraph (1) and section 
     1192 for services furnished under State plans under title XIX 
     to individuals who are 21 years of age or older but have not 
     attained age 65 for use under such plans and State plans 
     under title XXI. The format shall enable State agencies 
     administering such plans to collect data from managed care 
     entities and providers and practitioners that participate in 
     such plans and to report quality measures to the Secretary.
       ``(c) Development Process.--With respect to the development 
     of quality measures under subsections (a) and (b)--
       ``(1) Use of qualified entities.--The Secretary may enter 
     into agreements with public, nonprofit, or academic 
     institutions with technical expertise in the area of health 
     quality measurement to assist in such development. The 
     Secretary may carry out these agreements by contract, grant, 
     or otherwise.
       ``(2) Multi-stakeholder pre-rulemaking input.--The 
     Secretary shall obtain the input of stakeholders with respect 
     to such quality measures using a process similar to that 
     described in section 1808(d).
       ``(3) Coordination.--The Secretary shall coordinate the 
     development of such measures under such subsections and with 
     the development of child health quality measures under 
     section 1139A.
       ``(d) Annual Report to Congress.--No later than January 1, 
     2013, and annually thereafter, the Secretary shall report to 
     the Committee on Energy and Commerce of the House of 
     Representatives the Committee on Finance of the Senate 
     regarding--
       ``(1) the availability of reliable data relating to the 
     quality of maternity care furnished under State plans under 
     titles XIX and XXI;
       ``(2) the availability of reliable data relating to the 
     quality of services furnished under State plans under title 
     XIX to adults who are 21 years of age or older but have not 
     attained age 65; and
       ``(3) recommendations for improving the quality of such 
     care and services furnished under such State plans.
       ``(e) Rule of Construction.--Notwithstanding any other 
     provision in this section, no quality measure developed, 
     published, or used as a basis of measurement or reporting 
     under this section may be used to establish an irrebuttable 
     presumption regarding either the medical necessity of care or 
     the maximum permissible coverage for any individual who 
     receives medical assistance under title XIX or child health 
     assistance under title XXI.
       ``(f) Appropriation.--For purposes of carrying out this 
     section, in addition to funds otherwise available, out of any 
     funds in the Treasury not otherwise appropriated, there are 
     appropriated $40,000,000 for the 5-fiscal-year period 
     beginning with fiscal year 2010. Funds appropriated under 
     this subsection shall remain available until expended.''.

     SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

       (a) In General.--The Secretary of Health and Human Services 
     shall establish under this section an accountable care 
     program under which a State may apply to the Secretary for 
     approval of an accountable care organization pilot program 
     described in subsection (b) (in this section referred to as a 
     ``pilot program'') for the application of the accountable 
     care organization concept under title XIX of the Social 
     Security Act.
       (b) Pilot Program Described.--
       (1) In general.--The pilot program described in this 
     subsection is a program that applies one or more of the 
     accountable care organization models described in section 
     1866E of the Social Security Act, as added by section 1301 of 
     this Act.
       (2) Limitation.--The pilot program shall operate for a 
     period of not more than 5 years.
       (c) Additional Incentives.--In the case of the pilot 
     program under this section, the Secretary may--
       (1) waive the requirements of--
       (A) section 1902(a)(1) of the Social Security Act (relating 
     to statewideness);
       (B) section 1902(a)(10)(B) of such Act (relating to 
     comparability); and
       (2) increase the matching percentage for administrative 
     expenditures up to--
       (A) 90 percent (for the first 2 years of the pilot 
     program); and
       (B) 75 percent (for the next 3 years).
       (d) Evaluation; Report.--
       (1) Evaluation.--The Secretary shall conduct an evaluation 
     of the pilot program under this section. In conducting such 
     evaluation, the Secretary shall use the criteria used under 
     subsection (g)(1) of section 1866E of the Social Security Act 
     (as inserted by section 1301 of this Act) to evaluate pilot 
     programs under such section.
       (2) Report.--Not later than 60 days after the date of 
     completion of the evaluation under paragraph (1), the 
     Secretary shall submit to Congress and make available to the 
     public a report on the findings of the evaluation under such 
     paragraph.

     SEC. 1730B. FQHC COVERAGE.

       Section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 
     1396d(l)(2)(B)) is amended--
       (1) by striking ``or'' at the end of clause (iii);
       (2) by striking the semicolon at the end of clause (iv) and 
     inserting ``, and''; and
       (3) by inserting after clause (iv) the following new 
     clause:
       ``(v) is receiving a grant under section 399Z-1 of the 
     Public Health Service Act;''.

                          Subtitle D--Coverage

     SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-
                   INFECTED INDIVIDUALS.

       (a) In General.--Section 1902 of the Social Security Act 
     (42 U.S.C. 1396a), as amended by section 1714(a)(1), is 
     amended--
       (1) in subsection (a)(10)(A)(ii)--
       (A) by striking ``or'' at the end of subclause (XIX);
       (B) by adding ``or'' at the end of subclause (XX); and
       (C) by adding at the end the following:

       ``(XXI) who are described in subsection (ii) (relating to 
     HIV-infected individuals);''; and

       (2) by adding at the end, as amended by sections 1703 and 
     1714(a), the following:
       ``(ii) Individuals described in this subsection are 
     individuals not described in subsection (a)(10)(A)(i)--
       ``(1) who have HIV infection;
       ``(2) whose income (as determined under the State plan 
     under this title with respect to disabled individuals) does 
     not exceed the maximum amount of income a disabled individual 
     described in subsection (a)(10)(A)(i) may have and obtain 
     medical assistance under the plan; and
       ``(3) whose resources (as determined under the State plan 
     under this title with respect to disabled individuals) do not 
     exceed the maximum amount of resources a disabled individual 
     described in subsection (a)(10)(A)(i) may have and obtain 
     medical assistance under the plan.''.
       (b) Enhanced Match.--The first sentence of section 1905(b) 
     of such Act (42 U.S.C. 1396d(b)) is amended by striking 
     ``section 1902(a)(10)(A)(ii)(XVIII)'' and inserting 
     ``subclause (XVIII) or (XXI) of section 1902(a)(10)(A)(ii)''.
       (c) Conforming Amendments.--Section 1905(a) of such Act (42 
     U.S.C. 1396d(a)) is amended, in the matter preceding 
     paragraph (1)--
       (1) by striking ``or'' at the end of clause (xii);
       (2) by adding ``or'' at the end of clause (xiii); and
       (3) by inserting after clause (xiii) the following:
       ``(xiv) individuals described in section 1902(ii),''.
       (d) Exemption From Funding Limitation for Territories.--
     Section 1108(g) of the Social Security Act (42 U.S.C. 
     1308(g)) is amended by adding at the end the following:
       ``(5) Disregarding medical assistance for optional low-
     income hiv-infected individuals.--The limitations under 
     subsection (f) and the previous provisions of this subsection 
     shall not apply to amounts expended for medical assistance 
     for individuals described in section 1902(ii) who are only 
     eligible for such assistance on the basis of section 
     1902(a)(10)(A)(ii)(XXI).''.
       (e) Effective Date; Sunset.--The amendments made by this 
     section shall apply to expenditures for calendar quarters 
     beginning

[[Page 27331]]

     on or after the date of the enactment of this Act, and before 
     January 1, 2013, without regard to whether or not final 
     regulations to carry out such amendments have been 
     promulgated by such date.

     SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSISTANCE (TMA).

       Sections 1902(e)(1)(B) and 1925(f) of the Social Security 
     Act (42 U.S.C. 1396a(e)(1)(B), 1396r-6(f)), as amended by 
     section 5004(a)(1) of the American Recovery and Reinvestment 
     Act of 2009 (Public Law 111-5), are each amended by striking 
     ``December 31, 2010'' and inserting ``December 31, 2012''.

     SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER 
                   CERTAIN CHIP PROGRAMS.

       (a) In General.--Section 2102(b) of the Social Security Act 
     (42 U.S.C. 1397bb(b)) is amended by adding at the end the 
     following new paragraph:
       ``(6) Requirement for 12-month continuous eligibility.--In 
     the case of a State child health plan that provides child 
     health assistance under this title through a means other than 
     described in section 2101(a)(2), the plan shall provide for 
     implementation under this title of the 12-month continuous 
     eligibility option described in section 1902(e)(12) for 
     targeted low-income children whose family income is below 200 
     percent of the poverty line.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to determinations (and redeterminations) of 
     eligibility made on or after January 1, 2010.

     SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF COVERAGE 
                   WAITING PERIODS FOR CERTAIN CHILDREN.

       (a) In General.--Section 2102(b)(1) of the Social Security 
     Act (42 U.S.C. 1397bb(b)(1)) is amended--
       (1) in subparagraph (B)--
       (A) in clause (iii), by striking ``and'' at the end;
       (B) in clause (iv), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following new clause:
       ``(v) may not apply a waiting period (including a waiting 
     period to carry out paragraph (3)(C)) in the case of a child 
     described in subparagraph (C).''; and
       (2) by adding at the end the following new subparagraph:
       ``(C) Description of children not subject to waiting 
     period.--For purposes of this paragraph, a child described in 
     this subparagraph is a child who, on the date an application 
     is submitted for such child for child health assistance under 
     this title, meets any of the following requirements:
       ``(i) Infants and toddlers.--The child is under two years 
     of age.
       ``(ii) Loss of group health plan coverage.--The child 
     previously had private health insurance coverage through a 
     group health plan or health insurance coverage offered 
     through an employer and lost such coverage due to--

       ``(I) termination of an individual's employment;
       ``(II) a reduction in hours that an individual works for an 
     employer;
       ``(III) elimination of an individual's retiree health 
     benefits; or
       ``(IV) termination of an individual's group health plan or 
     health insurance coverage offered through an employer.

       ``(iii) Unaffordable private coverage.--

       ``(I) In general.--The family of the child demonstrates 
     that the cost of health insurance coverage (including the 
     cost of premiums, co-payments, deductibles, and other cost 
     sharing) for such family exceeds 10 percent of the income of 
     such family.
       ``(II) Determination of family income.--For purposes of 
     subclause (I), family income shall be determined in the same 
     manner specified by the State for purposes of determining a 
     child's eligibility for child health assistance under this 
     title.''.

       (b) Effective Date.--The amendments made by this section 
     shall take effect as of the date that is 90 days after the 
     date of the enactment of this Act.

     SEC. 1735. ADULT DAY HEALTH CARE SERVICES.

       (a) In General.--The Secretary of Health and Human Services 
     shall not--
       (1) withhold, suspend, disallow, or otherwise deny Federal 
     financial participation under section 1903(a) of the Social 
     Security Act (42 U.S.C. 1396b(a)) for the provision of adult 
     day health care services, day activity and health services, 
     or adult medical day care services, as defined under a State 
     Medicaid plan approved during or before 1994, during such 
     period if such services are provided consistent with such 
     definition and the requirements of such plan; or
       (2) withdraw Federal approval of any such State plan or 
     part thereof regarding the provision of such services (by 
     regulation or otherwise).
       (b) Effective Date.--Subsection (a) shall apply with 
     respect to services provided on or after October 1, 2008.

     SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY 
                   ASSOCIATED STATES.

       (a) In General.--Section 402(b)(2) of the Personal 
     Responsibility and Work Opportunity Reconciliation Act of 
     1996 (8 U.S.C. 1612(b)(2)) is amended by adding at the end 
     the following:
       ``(G) Medicaid exception for citizens of freely associated 
     states.--With respect to eligibility for benefits for the 
     designated Federal program defined in paragraph (3)(C) 
     (relating to the Medicaid program), section 401(a) and 
     paragraph (1) shall not apply to any individual who lawfully 
     resides in 1 of the 50 States or the District of Columbia in 
     accordance with the Compacts of Free Association between the 
     Government of the United States and the Governments of the 
     Federated States of Micronesia, the Republic of the Marshall 
     Islands, and the Republic of Palau and shall not apply, at 
     the option of the Governor of Puerto Rico, the Virgin 
     Islands, Guam, the Northern Mariana Islands, or American 
     Samoa as communicated to the Secretary of Health and Human 
     Services in writing, to any individual who lawfully resides 
     in the respective territory in accordance with such 
     Compacts.''.
       (b) Exception to 5-Year Limited Eligibility.--Section 
     403(d) of such Act (8 U.S.C. 1613(d)) is amended--
       (1) in paragraph (1), by striking ``or'' at the end;
       (2) in paragraph (2), by striking the period at the end and 
     inserting ``; or''; and
       (3) by adding at the end the following:
       ``(3) an individual described in section 402(b)(2)(G), but 
     only with respect to the designated Federal program defined 
     in section 402(b)(3)(C).''.
       (c) Definition of Qualified Alien.--Section 431(b) of such 
     Act (8 U.S.C. 1641(b)) is amended--
       (1) in paragraph (6), by striking ``; or'' at the end and 
     inserting a comma;
       (2) in paragraph (7), by striking the period at the end and 
     inserting ``, or''; and
       (3) by adding at the end the following:
       ``(8) an individual who lawfully resides in the United 
     States in accordance with a Compact of Free Association 
     referred to in section 402(b)(2)(G), but only with respect to 
     the designated Federal program defined in section 
     402(b)(3)(C) (relating to the Medicaid program).''.

     SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COVERAGE OF 
                   NONEMERGENCY TRANSPORTATION TO MEDICALLY 
                   NECESSARY SERVICES.

       (a) Requirement.--Section 1902(a)(10) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)) is amended--
       (1) in subparagraph (A), in the matter preceding clause 
     (i), by striking ``and (21)'' and inserting ``, (21), and 
     (30)''; and
       (2) in subparagraph (C)(iv), by striking ``and (17)'' and 
     inserting ``, (17), and (30)''.
       (b) Description of Services.--Section 1905(a) of such Act 
     (42 U.S.C. 1395d(a)), as amended by sections 1713(a)(1) and 
     1724(a)(1), is amended--
       (1) in paragraph (29), by striking ``and'' at the end;
       (2) by redesignating paragraph (30) as paragraph (31) and 
     by striking the comma at the end and inserting a semicolon; 
     and
       (3) by inserting after paragraph (29) the following new 
     paragraph:
       ``(30) nonemergency transportation to medically necessary 
     services, consistent with the requirement of section 431.53 
     of title 42, Code of Federal Regulations, as in effect as of 
     June 1, 2008; and''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act 
     and shall apply to transportation on or after such date.

     SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME IN 
                   PROVIDING CONTINUED MEDICAID COVERAGE FOR 
                   CERTAIN INDIVIDUALS WITH EXTREMELY HIGH 
                   PRESCRIPTION COSTS.

       Section 1902(e) of the Social Security Act (42 U.S.C. 
     1396b(e)), as amended by section 203(a) of the Children's 
     Health Insurance Program Reauthorization Act of 2009 (Public 
     Law 111-3), is amended by adding at the end the following new 
     paragraph:
       ``(14)(A) At the option of the State, in the case of an 
     individual with extremely high prescription drug costs 
     described in subparagraph (B) who has been determined 
     (without the application of this paragraph) to be eligible 
     for medical assistance under this title, the State may, in 
     redetermining the individual's eligibility for medical 
     assistance under this title, disregard any family income of 
     the individual to the extent such income is less than an 
     amount that is specified by the State and does not exceed the 
     amount specified in subparagraph (C), or, if greater, income 
     equal to the cost of the orphan drugs described in 
     subparagraph (B)(iii).
       ``(B) An individual with extremely high prescription drug 
     costs described in this subparagraph for a 12-month period is 
     an individual--
       ``(i) who is covered under health insurance or a health 
     benefits plan that has a maximum lifetime limit of not less 
     than $1,000,000 which includes all prescription drug 
     coverage;
       ``(ii) who has exhausted all available prescription drug 
     coverage under the plan as of the beginning of such period;
       ``(iii) who incurs (or is reasonably expected to incur) on 
     an annual basis during the period costs for orphan drugs in 
     excess of the amount specified in subparagraph (C) for the 
     period; and
       ``(iv) whose annual family income (determined without 
     regard to this paragraph) as

[[Page 27332]]

     of the beginning of the period does not exceed 75 percent of 
     the amount incurred for such drugs (as described in clause 
     (iii)).
       ``(C) The amount specified in this subparagraph for a 12-
     month period beginning in--
       ``(i) 2009 or 2010, is $200,000; or
       ``(ii) a subsequent year, is the amount specified in clause 
     (i) (or this subparagraph) for the previous year increased by 
     the annual rate of increase in the medical care component of 
     the consumer price index (U.S. city average) for the 12-month 
     period ending in August of the previous year.

     Any amount computed under clause (ii) that is not a multiple 
     of $1,000 shall be rounded to the nearest multiple of $1,000.
       ``(D) In applying this paragraph, amounts incurred for 
     prescription drugs for cosmetic purposes shall not be taken 
     into account.
       ``(E) With respect to an individual described in 
     subparagraph (A), notwithstanding section 1916, the State 
     plan--
       ``(i) shall provide for the application of cost-sharing 
     that is at least nominal as determined under section 1916; 
     and
       ``(ii) may provide, consistent with section 1916A, for such 
     additional cost-sharing as does not exceed a maximum level of 
     cost-sharing that is specified by the Secretary and is 
     adjusted by the Secretary on an annual basis.
       ``(F) A State electing the option under this paragraph 
     shall provide for a determination on an individual's 
     application for continued medical assistance under this title 
     within 30 days of the date the application if filed with the 
     State.
       ``(G) In this paragraph:
       ``(i) The term `orphan drugs' means prescription drugs 
     designated under section 526 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 360bb) as a drug for a rare disease 
     or condition.
       ``(ii) The term `health benefits plan' includes coverage 
     under a plan offered under a State high risk pool.''.

     SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING ASSISTANCE 
                   SERVICES AND SUPPORTS (CLASS).

       (a) Coordination With CLASS Provisions.--Section 1902(a) of 
     the Social Security Act (42 U.S.C. 1396a(a)), as amended by 
     sections 1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a), 
     1783(a), and 1907(b), is amended--
       (1) in paragraph (80), by striking ``and'' at the end;
       (2) in paragraph (81), by striking the period and inserting 
     ``; and''; and
       (3) by inserting after paragraph (81) the following:
       ``(82) provide that the State will comply with such 
     regulations regarding the application of primary and 
     secondary payor rules with respect to individuals who are 
     eligible for medical assistance under this title and are 
     eligible beneficiaries under the CLASS program established 
     under title XXXII of the Public Health Service Act as the 
     Secretary shall establish.''.
       (b) Assurance of Adequate Infrastructure for the Provision 
     of Personal Care Attendant Workers.--Section 1902(a) of such 
     Act (42 U.S.C. 1396a(a)), as amended by subsection (a), is 
     amended--
       (1) in paragraph (81), by striking ``and'' at the end;
       (2) in paragraph (82), by striking the period at the end 
     and inserting ``; and''; and
       (3) by inserting after paragraph (82), the following:
       ``(83) provide that, not later than 2 years after the date 
     of enactment of this paragraph, each State shall--
       ``(A) assess the extent to which entities such as providers 
     of home care, home health services, home and community 
     service providers, public authorities created to provide 
     personal care services to individuals eligible for medical 
     assistance under the State plan, and nonprofit organizations, 
     are serving or have the capacity to serve as fiscal agents 
     for, employers of, and providers of employment-related 
     benefits for, personal care attendant workers who provide 
     personal care services to individuals receiving benefits 
     under the CLASS program established under title XXXII of the 
     Public Health Service Act, including in rural and underserved 
     areas;
       ``(B) designate or create such entities to serve as fiscal 
     agents for, employers of, and providers of employment-related 
     benefits for, such workers to ensure an adequate supply of 
     the workers for individuals receiving benefits under the 
     CLASS program, including in rural and underserved areas; and
       ``(C) ensure that the designation or creation of such 
     entities will not negatively alter or impede existing 
     programs, models, methods, or administration of service 
     delivery that provide for consumer controlled or self-
     directed home and community services and further ensure that 
     such entities will not impede the ability of individuals to 
     direct and control their home and community services, 
     including the ability to select, manage, dismiss, co-employ, 
     or employ such workers or inhibit such individuals from 
     relying on family members for the provision of personal care 
     services.''.
       (c) Inclusion of Information on Supplemental Coverage in 
     the National Clearinghouse for Long-Term Care Information; 
     Extension of Funding.--Section 6021(d) of the Deficit 
     Reduction Act of 2005 (42 U.S.C. 1396p note) is amended--
       (1) in paragraph (2)(A)--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) in clause (iii), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(iv) include information regarding the CLASS program 
     established under title XXXII of the Public Health Service 
     Act.''; and
       (2) in paragraph (3)--
       (A) by striking ``2010'' and inserting ``2015''; and
       (B) by adding at the end the following: ``In addition to 
     the amount appropriated under the previous sentence, there 
     are authorized to be appropriated to carry out this 
     subsection, $7,000,000 for each of fiscal years 2011, 2012, 
     and 2013.''.
       (d) Effective Date.--The amendments made by this section 
     take effect on January 1, 2011.

     SEC. 1739A. SENSE OF CONGRESS REGARDING COMMUNITY FIRST 
                   CHOICE OPTION TO PROVIDE MEDICAID COVERAGE OF 
                   COMMUNITY-BASED ATTENDANT SERVICES AND 
                   SUPPORTS.

       It is the sense of Congress that States should be allowed 
     to elect under their Medicaid State plans under title XIX of 
     the Social Security Act to implement a Community First Choice 
     Option under which--
       (1) coverage of community-based attendant services and 
     supports furnished in homes and communities is available, at 
     an individual's option, to individuals who would otherwise 
     qualify for Medicaid institutional coverage under the 
     respective State plan;
       (2) such supports and services include assistance to 
     individuals with disabilities in accomplishing activities of 
     daily living, instrumental activities of daily living, and 
     health-related tasks;
       (3) the Federal matching assistance percentage (FMAP) under 
     such title for medical assistance for such supports and 
     services is enhanced;
       (4) States, consistent with minimum federal standards, 
     ensure quality of such supports and services; and
       (5) States collect and provide data to the Secretary of 
     Health and Human Services on the cost and effectiveness and 
     quality of supports and services provided through such 
     option.

                         Subtitle E--Financing

     SEC. 1741. PAYMENTS TO PHARMACISTS.

       (a) Pharmacy Reimbursement Limits.--
       (1) In general.--Section 1927(e) of the Social Security Act 
     (42 U.S.C. 1396r-8(e)) is amended--
       (A) by striking paragraph (5) and inserting the following:
       ``(5) Use of amp in upper payment limits.--The Secretary 
     shall calculate the Federal upper reimbursement limit 
     established under paragraph (4) as 130 percent of the 
     weighted average (determined on the basis of manufacturer 
     utilization) of monthly average manufacturer prices. Nothing 
     in the previous sentence shall be construed as preventing the 
     Secretary from performing such calculation using a smoothing 
     process in order to reduce significant variations from month 
     to month as a result of rebates, discounts, and other pricing 
     practices, such as in the manner such a process is used by 
     the Secretary in determining the average sales price of a 
     drug or biological under section 1847A.''
       (2) Definition of amp.--Section 1927(k)(1)(B) of such Act 
     (42 U.S.C. 1396r-8(k)(1)(B)) is amended--
       (B) in the heading, by striking ``extended to wholesalers'' 
     and inserting ``and other payments''; and
       (C) by striking ``regard to'' and all that follows through 
     the period and inserting the following: ``regard to--
       ``(i) customary prompt pay discounts extended to 
     wholesalers;
       ``(ii) bona fide service fees paid by manufacturers;
       ``(iii) reimbursement by manufacturers for recalled, 
     damaged, expired, or otherwise unsalable returned goods, 
     including reimbursement for the cost of the goods and any 
     reimbursement of costs associated with return goods handling 
     and processing, reverse logistics, and drug destruction;
       ``(iv) sales directly to, or rebates, discounts, or other 
     price concessions provided to, pharmacy benefit managers, 
     managed care organizations, health maintenance organizations, 
     insurers, mail order pharmacies that are not open to all 
     members of the public, or long term care providers, provided 
     that these rebates, discounts, or price concessions are not 
     passed through to retail pharmacies;
       ``(v) sales directly to, or rebates, discounts, or other 
     price concessions provided to, hospitals, clinics, and 
     physicians, unless the drug is an inhalation, infusion, or 
     injectable drug, or unless the Secretary determines, as 
     allowed for in Agency administrative procedures, that it is 
     necessary to include such sales, rebates, discounts, and 
     price concessions in order to obtain an accurate AMP for the 
     drug. Such a determination shall not be subject to judicial 
     review; or
       ``(vi) rebates, discounts, and other price concessions 
     required to be provided under agreements under subsections 
     (f) and (g) of section 1860D-2(f).''.
       (3) Manufacturer reporting requirements.--Section 
     1927(b)(3)(A) of such Act (42 U.S.C. 1396r-8(b)(3)(A)) is 
     amended--

[[Page 27333]]

       (A) in clause (ii), by striking ``and'' at the end;
       (B) by striking the period at the end of clause (iii) and 
     inserting ``; and''; and
       (C) by inserting after clause (iii) the following new 
     clause:
       ``(iv) not later than 30 days after the last day of each 
     month of a rebate period under the agreement, on the 
     manufacturer's total number of units that are used to 
     calculate the monthly average manufacturer price for each 
     covered outpatient drug.''.
       (4) Authority to promulgate regulation.--The Secretary of 
     Health and Human Services may promulgate regulations to 
     clarify the requirements for upper payment limits and for the 
     determination of the average manufacturer price in an 
     expedited manner. Such regulations may become effective on an 
     interim final basis, pending opportunity for public comment.
       (5) Pharmacy reimbursements through december 31, 2010.--The 
     specific upper limit under section 447.332 of title 42, Code 
     of Federal Regulations (as in effect on December 31, 2006) 
     applicable to payments made by a State for multiple source 
     drugs under a State Medicaid plan shall continue to apply 
     through December 31, 2010, for purposes of the availability 
     of Federal financial participation for such payments.
       (b) Disclosure of Price Information to the Public.--Section 
     1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
       (1) in subparagraph (A)--
       (A) in clause (i), in the matter preceding subclause (I), 
     by inserting ``month of a'' after ``each''; and
       (B) in the last sentence, by striking ``and shall,'' and 
     all that follows up to the period; and
       (2) in subparagraph (D)(v), by inserting ``weighted'' 
     before ``average manufacturer prices''.

     SEC. 1742. PRESCRIPTION DRUG REBATES.

       (a) Additional Rebate for New Formulations of Existing 
     Drugs.--
       (1) In general.--Section 1927(c)(2) of the Social Security 
     Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end 
     the following new subparagraph:
       ``(C) Treatment of new formulations.--In the case of a drug 
     that is a line extension of a single source drug or an 
     innovator multiple source drug that is an oral solid dosage 
     form, the rebate obligation with respect to such drug under 
     this section shall be the amount computed under this section 
     for such new drug or, if greater, the product of--
       ``(i) the average manufacturer price of the line extension 
     of a single source drug or an innovator multiple source drug 
     that is an oral solid dosage form;
       ``(ii) the highest additional rebate (calculated as a 
     percentage of average manufacturer price) under this section 
     for any strength of the original single source drug or 
     innovator multiple source drug; and
       ``(iii) the total number of units of each dosage form and 
     strength of the line extension product paid for under the 
     State plan in the rebate period (as reported by the State).
     In this subparagraph, the term `line extension' means, with 
     respect to a drug, a new formulation of the drug, such as an 
     extended release formulation.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to drugs dispensed after December 31, 2009.
       (b) Increase Minimum Rebate Percentage for Single Source 
     Drugs.--
       (1) In general.--Section 1927(c)(1)(B)(i) of the Social 
     Security Act (42 U.S.C. 1396r-8(c)(1)(B)(i)) is amended--
       (A) in subclause (IV), by striking ``and'' at the end;
       (B) in subclause (V)--
       (i) by inserting ``and before January 1, 2010'' after 
     ``December 31, 1995,''; and
       (ii) by striking the period at the end and inserting ``; 
     and''; and
       (C) by adding at the end the following new subclause:

       ``(VI) after December 31, 2009, is 23.1 percent.''.

       (2) Recapture of total savings due to increase.--Section 
     1927(b)(1) of such Act is amended by adding at the end the 
     following new subparagraph:
       ``(C) Special rule for increased minimum rebate 
     percentage.--
       ``(i) In general.--In addition to the amounts applied as a 
     reduction under subparagraph (B), for rebate periods 
     beginning on or after January 1, 2010, during a fiscal year, 
     the Secretary shall reduce payments to a State under section 
     1903(a) in the manner specified in clause (ii), in an amount 
     equal to the product of--

       ``(I) 100 percent minus the Federal medical assistance 
     percentage applicable to the rebate period for the State; and
       ``(II) the amounts received by the State under such 
     subparagraph that are attributable (as estimated by the 
     Secretary based on utilization and other data) to the 
     increase in the minimum rebate percentage effected by the 
     amendments made by section 1742(b)(1) of the Affordable 
     Health Care for America Act, taking into account the 
     additional drugs included under the amendments made by 
     section 1743 of such Act.

     The Secretary shall adjust such payment reduction for a 
     calendar quarter to the extent the Secretary determines, 
     based upon subsequent utilization and other data, that the 
     reduction for such quarter was greater or less than the 
     amount of payment reduction that should have been made.
       ``(ii) Manner of payment reduction.--The amount of the 
     payment reduction under clause (i) for a State for a quarter 
     shall be deemed an overpayment to the State under this title 
     to be disallowed against the State's regular quarterly draw 
     for all Medicaid spending under section 1903(d)(2). Such a 
     disallowance is not subject to a reconsideration under 
     1116(d).''.

     SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO 
                   ENROLLEES OF MEDICAID MANAGED CARE 
                   ORGANIZATIONS.

       (a) In General.--Section 1903(m)(2)(A) of the Social 
     Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended--
       (1) in clause (xi), by striking ``and'' at the end;
       (2) in clause (xii), by striking the period at the end and 
     inserting ``; and''; and
       (3) by adding at the end the following:
       ``(xiii) such contract provides that the entity shall 
     report to the State such information, on such timely and 
     periodic basis as specified by the Secretary, as the State 
     may require in order to include, in the information submitted 
     by the State to a manufacturer under section 1927(b)(2)(A) 
     and to the Secretary under section 1927(b)(2)(C), information 
     on covered outpatient drugs dispensed to individuals eligible 
     for medical assistance who are enrolled with the entity and 
     for which the entity is responsible for coverage of such 
     drugs under this subsection.''.
       (b) Conforming Amendments.--Section 1927 of such Act (42 
     U.S.C. 1396r-8) is amended----
       (1) in the first sentence of subsection (b)(1)(A), by 
     inserting before the period at the end the following: ``, 
     including such drugs dispensed to individuals enrolled with a 
     medicaid managed care organization if the organization is 
     responsible for coverage of such drugs'';
       (2) in subsection (b)(2), by adding at the end the 
     following new subparagraph:
       ``(C) Reporting on mmco drugs.--On a quarterly basis, each 
     State shall report to the Secretary the total amount of 
     rebates in dollars received from pharmacy manufacturers for 
     drugs provided to individuals enrolled with Medicaid managed 
     care organizations that contract under section 1903(m) and 
     such other information as the Secretary may require to carry 
     out paragraph (1)(C) with respect to such rebates.''; and
       (3) in subsection (j)--
       (A) in the heading by striking ``Exemption'' and inserting 
     ``Special Rules''; and
       (B) in paragraph (1), by striking ``are not subject to the 
     requirements of this section'' and inserting ``are subject to 
     the requirements of this section unless such drugs are 
     subject to discounts under section 340B of the Public Health 
     Service Act''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2010, and shall apply to drugs 
     dispensed on or after such date, without regard to whether or 
     not final regulations to carry out such amendments have been 
     promulgated by such date.

     SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d), as amended by sections 1701(a)(3)(B), 
     1711(a), and 1713(a), is amended by adding at the end the 
     following new subsection:
       ``(bb) Payment for Graduate Medical Education.--
       ``(1) In general.--The term `medical assistance' includes 
     payment for costs of graduate medical education consistent 
     with this subsection, whether provided in or outside of a 
     hospital.
       ``(2) Submission of information.--For purposes of paragraph 
     (1) and section 1902(a)(13)(A)(v), payment for such costs is 
     not consistent with this subsection unless--
       ``(A) the State submits to the Secretary, in a timely 
     manner and on an annual basis specified by the Secretary, 
     information on total payments for graduate medical education 
     and how such payments are being used for graduate medical 
     education, including--
       ``(i) the institutions and programs eligible for receiving 
     the funding;
       ``(ii) the manner in which such payments are calculated;
       ``(iii) the types and fields of education being supported;
       ``(iv) the workforce or other goals to which the funding is 
     being applied;
       ``(v) State progress in meeting such goals; and
       ``(vi) such other information as the Secretary determines 
     will assist in carrying out paragraphs (3) and (4); and
       ``(B) such expenditures are made consistent with such goals 
     and requirements as are established under paragraph (4).
       ``(3) Review of information.--The Secretary shall make the 
     information submitted under paragraph (2) available to the 
     Advisory Committee on Health Workforce Evaluation and 
     Assessment (established under section 2261 of the Public 
     Health Service Act). The Secretary and the Advisory Committee 
     shall independently review the information submitted under 
     paragraph (2), taking into account State and local workforce 
     needs.

[[Page 27334]]

       ``(4) Specification of goals and requirements.--The 
     Secretary shall specify by rule, initially published by not 
     later than December 31, 2011--
       ``(A) program goals for the use of funds described in 
     paragraph (1), taking into account recommendations of the 
     such Advisory Committee and the goals for approved medical 
     residency training programs described in section 
     1886(h)(1)(B); and
       ``(B) requirements for use of such funds consistent with 
     such goals.
     Such rule may be effective on an interim basis pending 
     revision after an opportunity for public comment.''.
       (b) Conforming Amendment.--Section 1902(a)(13)(A) of such 
     Act (42 U.S.C. 1396a(a)(13)(A)), as amended by section 
     1721(a)(1)(A), is amended--
       (1) by striking ``and'' at the end of clause (iii);
       (2) by striking the semicolon in clause (iv) and inserting 
     ``, and''; and
       (3) by adding at the end the following new clause:
       ``(v) in the case of hospitals and at the option of a 
     State, such rates may include, to the extent consistent with 
     section 1905(bb), payment for graduate medical education; 
     and''.
       (c) Effective Date.--The amendments made by this section 
     shall take effect on the date of the enactment of this Act. 
     Nothing in this section shall be construed as affecting 
     payments made before such date under a State plan under title 
     XIX of the Social Security Act for graduate medical 
     education.

     SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT PROGRAM.

       (a) Total Amount Available for Payments.--
       (1) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') to carry out this section 
     $6,000,000,000, of which the following amounts shall be 
     available for obligation in the following years:
       (A) $1,500,000,000 shall be available beginning in 2010.
       (B) $1,500,000,000 shall be available beginning in 2011.
       (C) $1,500,000,000 shall be available beginning in 2012.
       (D) $1,500,000,000 shall be available beginning in 2013.
       (2) Availability.--Funds appropriated under paragraph (1) 
     shall remain available until all eligible dually-certified 
     facilities (as defined in subsection (b)(3)) have been 
     reimbursed for underpayments under this section during cost 
     reporting periods ending during calendar years 2010 through 
     2013.
       (3) Limitation of authority.--The Secretary may not make 
     payments under this section that exceed the funds 
     appropriated under paragraph (1).
       (4) Disposition of remaining funds into mif.--Any funds 
     appropriated under paragraph (1) which remain available after 
     the application of paragraph (2) shall be deposited into the 
     Medicaid Improvement Fund under section 1941 of the Social 
     Security Act.
       (b) Use of Funds.--
       (1) Authority to make payments.--From the amounts available 
     for obligation in a year under subsection (a), the Secretary, 
     acting through the Administrator of the Centers for Medicare 
     & Medicaid Services, shall pay the amount determined under 
     paragraph (2) directly to an eligible dually-certified 
     facility for the purpose of providing funding to reimburse 
     such facility for furnishing quality care to Medicaid-
     eligible individuals.
       (2) Determination of payment amounts.--
       (A) In general.--Subject to subparagraphs (B) and (C), the 
     payment amount determined under this paragraph for a year for 
     an eligible dually-certified facility shall be an amount 
     determined by the Secretary as reported on the facility's 
     latest available Medicare cost report.
       (B) Limitation on payment amount.--In no case shall the 
     payment amount for an eligible dually-certified facility for 
     a year under subparagraph (A) be more than the payment 
     deficit described in paragraph (3)(D) for such facility as 
     reported on the facility's latest available Medicare cost 
     report.
       (C) Pro-rata reduction.--If the amount available for 
     obligation under subsection (a) for a year (as reduced by 
     allowable administrative costs under this section) is 
     insufficient to ensure that each eligible dually-certified 
     facility receives the amount of payment calculated under 
     subparagraph (A), the Secretary shall reduce that amount of 
     payment with respect to each such facility in a pro-rata 
     manner to ensure that the entire amount available for such 
     payments for the year be paid.
       (D) No required match.--The Secretary may not require that 
     a State provide matching funds for any payment made under 
     this subsection.
       (3) Eligible dually-certified facility defined.--For 
     purposes of this section, the term ``eligible dually-
     certified facility'' means, for a cost reporting period 
     ending during a year (beginning no earlier than 2010) that is 
     covered by the latest available Medicare cost report, a 
     nursing facility that meets all of the following 
     requirements:
       (A) The facility is participating as a nursing facility 
     under title XIX of the Social Security Act and as a skilled 
     nursing facility under title XVIII of such Act during the 
     entire year.
       (B) The base Medicaid payment rate (excluding any 
     supplemental payments) to the facility is not less than the 
     base Medicaid payment rate (excluding any supplemental 
     payments) to such facility as of June 16, 2009.
       (C) As reported on the facility's latest Medicare cost 
     report--
       (i) the Medicaid share of patient days for such facility is 
     not less than 60 percent of the combined Medicare and 
     Medicaid share of resident days for such facility; and
       (ii) the combined Medicare and Medicaid share of resident 
     days for such facility, as reported on the facility's latest 
     available Medicare cost report, is not less than 75 percent 
     of the total resident days for such facility.
       (D) The facility has received Medicaid reimbursement 
     (including any supplemental payments) for the provision of 
     covered services to Medicaid eligible individuals, as 
     reported on the facility's latest available Medicare cost 
     report, that is significantly less (as determined by the 
     Secretary) than the allowable costs (as determined by the 
     Secretary) incurred by the facility in providing such 
     services.
       (E) The facility is not in the highest quartile of costs 
     costs per day, as determined by the Secretary and as adjusted 
     for case mix, wages, and type of facility.
       (F) The facility provides quality care, as determined by 
     the Secretary, to--
       (i) Medicaid eligible individuals; and
       (ii) individuals who are entitled to items and services 
     under part A of title XVIII of the Social Security Act.
       (G) In the most recent standard survey available, the 
     facility was not cited for any immediate jeopardy 
     deficiencies as defined by the Secretary.
       (H) In the most recent standard survey available, the 
     facility maintains an appropriate staffing level to attain or 
     maintain the highest practicable well-being of each resident 
     as defined by the Secretary.
       (I) The facility complies with all the requirements, as 
     determined by the Secretary, contained in sections 1411 
     through 1416 and the amendments made by such sections.
       (J) The facility was not listed as a Centers for Medicare & 
     Medicaid Services Special Focus Facility (SFF) nor as a SFF 
     on a State-based list.
       (4) Frequency of payment.--Payment of an amount under this 
     subsection to an eligible dually-certified facility shall be 
     made for a year in a lump sum or in such periodic payments in 
     such frequency as the Secretary determines appropriate.
       (5) Direct payments.--Such payment--
       (A) shall be made directly by the Secretary to an eligible 
     dually-certified facility or a contractor designated by such 
     facility; and
       (B) shall not be made through a State.
       (c) Administration.--
       (1) Annual applications; deadlines.--The Secretary shall 
     establish a process, including deadlines, under which 
     facilities may apply on an annual basis to qualify as 
     eligible dually-certified facilities for payment under 
     subsection (b).
       (2) Contracting authority.--The Secretary may enter into 
     one or more contracts with entities for the purpose of 
     implementation of this section.
       (3) Limitation.--The Secretary may not spend more than 0.75 
     percent of the amount made available under subsection (a) in 
     any year on the costs of administering the program of 
     payments under this section for the year.
       (4) Implementation.--Notwithstanding any other provision of 
     law, the Secretary may implement, by program instruction or 
     otherwise, the provisions of this section.
       (5) Limitations on review.--There shall be no 
     administrative or judicial review of--
       (A) the determination of the eligibility of a facility for 
     payments under subsection (b); or
       (B) the determination of the amount of any payment made to 
     a facility under such subsection.
       (d) Annual Reports.--The Secretary shall submit an annual 
     report to the committees with jurisdiction in the Congress on 
     payments made under subsection (b). Each such report shall 
     include information on--
       (1) the facilities receiving such payments;
       (2) the amount of such payments to such facilities; and
       (3) the basis for selecting such facilities and the amount 
     of such payments.
       (e) Reference to Report.--For report by the Medicaid and 
     CHIP Payment and Access Commission on the adequacy of 
     payments to nursing facilities under the Medicaid program, 
     see section 1900(b)(2)(B) of the Social Security Act, as 
     amended by section 1784.
       (f) Definitions.--For purposes of this section:
       (1) Dually-certified facility.--The term ``dually-certified 
     facility'' means a facility that is participating as a 
     nursing facility under title XIX of the Social Security Act 
     and as a skilled nursing facility under title XVIII of such 
     Act.
       (2) Medicaid eligible individual.--The term ``Medicaid 
     eligible individual'' means an individual who is eligible for 
     medical assistance, with respect to nursing facility services 
     (as defined in section 1905(f) of the Social Security Act), 
     under title XIX of the such Act.

[[Page 27335]]

       (3) State.--The term ``State'' means the 50 States and the 
     District of Columbia.

     SEC. 1746. REPORT ON MEDICAID PAYMENTS.

       Section 1902 of the Social Security Act (42 U.S.C. 1396), 
     as amended by sections 1703(a), 1714(a), and 1731(a), is 
     amended by adding at the end the following new subsection:
       ``(jj) Report on Medicaid Payments.--Each year, on or 
     before a date determined by the Secretary, a State 
     participating in the Medicaid program under this title shall 
     submit to the Administrator of the Centers for Medicare & 
     Medicaid Services--
       ``(1) information on the determination of rates of payment 
     to providers for covered services under the State plan, 
     including--
       ``(A) the final rates;
       ``(B) the methodologies used to determine such rates; and
       ``(C) justifications for the rates; and
       ``(2) an explanation of the process used by the State to 
     allow providers, beneficiaries and their representatives, and 
     other concerned State residents a reasonable opportunity to 
     review and comment on such rates, methodologies, and 
     justifications before the State made such rates final.''.

     SEC. 1747. REVIEWS OF MEDICAID.

       (a) GAO Study on FMAP.--.
       (1) Study.--The Comptroller General of the United States 
     shall conduct a study regarding federal payments made to the 
     State Medicaid programs under title XIX of the Social 
     Security Act for the purposes of making recommendations to 
     Congress.
       (2) Report.--Not later than February 15, 2011, the 
     Comptroller General shall submit to the appropriate 
     committees of Congress a report on the study conducted under 
     paragraph (1) and the effect on the federal government, 
     States, providers, and beneficiaries of--
       (A) removing the 50 percent floor, or 83 percent ceiling, 
     or both, in the Federal medical assistance percentage under 
     section 1905(b)(1) of the Social Security Act; and
       (B) revising the current formula for such Federal medical 
     assistance percentage to better reflect State fiscal capacity 
     and State effort to pay for health and long-term care 
     services and to better adjust for national or regional 
     economic downturns.
       (b) GAO Study on Medicaid Administrative Costs..--
       (1) Study.--The Comptroller General of the United States 
     shall conduct a study of the administration of the Medicaid 
     program by the Department of Health and Human Services, State 
     Medicaid agencies, and local government agencies. The report 
     shall address the following issues:
       (A) The extent to which federal funds for each 
     administrative function, such as survey and certification and 
     claims processing, are being used effectively and 
     efficiently.
       (B) The administrative functions on which federal Medicaid 
     funds are expended and the amounts of such expenditures 
     (whether spent directly or by contract).
       (2) Report.--Not later than February 15, 2011, the 
     Comptroller General shall submit to the appropriate 
     committees of Congress a report on the study conducted under 
     paragraph (1).

     SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGANIZATION 
                   PROVIDER TAX ELIMINATION.

       Effective as if included in the enactment of section 6051 
     of the Deficit Reduction Act of 2005 (Public Law 109-171), 
     subsection (b)(2)(A) of such section is amended by striking 
     ``October 1, 2009'' and inserting ``October 1, 2010''.

     SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP.

       Section 5001 of the American Recovery and Reinvestment Act 
     of 2009 (Public Law 111-5) is amended--
       (1) in subsection (a)(3), by striking ``first calendar 
     quarter'' and inserting ``first 3 calendar quarters'';
       (2) in subsection (b)(2), by inserting before the period at 
     the end the following: ``and such paragraph shall not apply 
     to calendar quarters beginning on or after October 1, 2010'';
       (3) in subsection (c)(4)(C)(ii), by striking ``December 
     2009'' and ``January 2010'' and inserting ``June 2010'' and 
     ``July 2010'', respectively;
       (4) in subsection (d), by inserting ``ending before October 
     1, 2010'' after ``entire fiscal years'' and after ``with 
     respect to fiscal years'';
       (5) in subsection (g)(1), by striking ``September 30, 
     2011'' and inserting ``December 31, 2011''; and
       (6) in subsection (h)(3), by striking ``December 31, 2010'' 
     and inserting ``June 30, 2011''.

                  Subtitle F--Waste, Fraud, and Abuse

     SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS.

       (a) Medicaid Non-payment for Certain Health Care-acquired 
     Conditions.--Section 1903(i) of the Social Security Act (42 
     U.S.C. 1396b(i)) is amended--
       (1) by striking ``or'' at the end of paragraph (23);
       (2) by striking the period at the end of paragraph (24) and 
     inserting ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) with respect to amounts expended for services 
     related to the presence of a condition that could be 
     identified by a secondary diagnostic code described in 
     section 1886(d)(4)(D)(iv) and for any health care acquired 
     condition determined as a non-covered service under title 
     XVIII.''.
       (b) Application to CHIP.--Section 2107(e)(1)(G) of such Act 
     (42 U.S.C. 1397gg(e)(1)(G)) is amended by striking ``and 
     (17)'' and inserting ``(17), and (25)''.
       (c) Permission to Include Additional Health Care-acquired 
     Conditions.--Nothing in this section shall prevent a State 
     from including additional health care-acquired conditions for 
     non-payment in its Medicaid program under title XIX of the 
     Social Security Act.
       (d) Effective Date.--The amendments made by this section 
     shall apply to discharges occurring on or after January 1, 
     2010.

     SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICAID 
                   INTEGRITY PROGRAM.

       Section 1936(c)(2)) of the Social Security Act (42 U.S.C. 
     1396u-7(c)(2)) is amended--
       (1) by redesignating subparagraph (D) as subparagraph (E); 
     and
       (2) by inserting after subparagraph (C) the following new 
     subparagraph:
       ``(D) For the contract year beginning in 2011 and each 
     subsequent contract year, the entity provides assurances to 
     the satisfaction of the Secretary that the entity will 
     conduct periodic evaluations of the effectiveness of the 
     activities carried out by such entity under the Program and 
     will submit to the Secretary an annual report on such 
     activities.''.

     SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS 
                   TO REDUCE WASTE, FRAUD, AND ABUSE.

       Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 1396a(a)), 
     as amended by sections 1631(b)(1), 1703, and 1729, is further 
     amended--
       (1) in paragraph (75), by striking at the end ``and'';
       (2) in paragraph (76), by striking at the end the period 
     and inserting ``; and''; and
       (3) by inserting after paragraph (76) the following new 
     paragraph:
       ``(77) provide that any provider or supplier (other than a 
     physician or nursing facility) providing services under such 
     plan shall, subject to paragraph (5) of section 1874(d), 
     establish a compliance program described in paragraph (1) of 
     such section in accordance with such section.''.

     SEC. 1754. OVERPAYMENTS.

       (a) In General.--Section 1903(d)(2)(C) of the Social 
     Security Act (42 U.S.C. 1396b(d)(2)(C)) is amended--
       (1) in the first sentence, by inserting ``(or of 1 year in 
     the case of overpayments due to fraud)'' after ``60 days''; 
     and
       (2) in the second sentence, by striking ``the 60 days'' and 
     inserting ``such period''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply in the case of overpayments discovered on or 
     after the date of the enactment of this Act.

     SEC. 1755. MANAGED CARE ORGANIZATIONS.

       (a) Minimum Medical Loss Ratio.--
       (1) Medicaid.--Section 1903(m)(2)(A) of the Social Security 
     Act (42 U.S.C. 1396b(m)(2)(A)), as amended by section 
     1743(a)(3), is amended--
       (A) by striking ``and'' at the end of clause (xii);
       (B) by striking the period at the end of clause (xiii) and 
     inserting ``; and''; and
       (C) by adding at the end the following new clause:
       ``(xiv) such contract has a medical loss ratio, as 
     determined in accordance with a methodology specified by the 
     Secretary that is a percentage (not less than 85 percent) as 
     specified by the Secretary.''.
       (2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C. 
     1397gg(e)(1)) is amended--
       (A) by redesignating subparagraphs (H) through (L) as 
     subparagraphs (I) through (M); and
       (B) by inserting after subparagraph (G) the following new 
     subparagraph:
       ``(H) Section 1903(m)(2)(A)(xiv) (relating to application 
     of minimum loss ratios), with respect to comparable contracts 
     under this title.''.
       (3) Effective date.--The amendments made by this subsection 
     shall apply to contracts entered into or renewed on or after 
     July 1, 2010.
       (b) Patient Encounter Data.--
       (1) In general.--Section 1903(m)(2)(A)(xi) of the Social 
     Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by 
     inserting ``and for the provision of such data to the State 
     at a frequency and level of detail to be specified by the 
     Secretary'' after ``patients''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply with respect to contract years beginning on or 
     after January 1, 2010.

     SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION UNDER 
                   MEDICAID AND CHIP IF TERMINATED UNDER MEDICARE 
                   OR OTHER STATE PLAN OR CHILD HEALTH PLAN.

       (a) State Plan Requirement.--Section 1902(a)(39) of the 
     Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is amended 
     by inserting after ``1128A,'' the following: ``terminate the 
     participation of any individual or entity in such program if 
     (subject to such exceptions are permitted with respect to 
     exclusion under sections 1128(b)(3)(C) and 1128(d)(3)(B)) 
     participation of such individual or entity is terminated 
     under title XVIII,

[[Page 27336]]

     any other State plan under this title, or any child health 
     plan under title XXI,''.
       (b) Application to CHIP.--Section 2107(e)(1)(A) of such Act 
     (42 U.S.C. 1397gg(e)(1)(A)) is amended by inserting before 
     the period at the end the following: ``and section 
     1902(a)(39) (relating to exclusion and termination of 
     participation)''.
       (c) Effective Date.--Except as provided in section 1790, 
     the amendments made by this section shall apply to services 
     furnished on or after January 1, 2011, without regard to 
     whether or not final regulations to carry out such amendments 
     have been promulgated by such date.

     SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION 
                   RELATING TO CERTAIN OWNERSHIP, CONTROL, AND 
                   MANAGEMENT AFFILIATIONS.

       (a) State Plan Requirement.--Section 1902(a) of the Social 
     Security Act (42 U.S.C. 1396a(a)), as amended by sections 
     1631(b)(1), 1703(a), 1729, and 1753, is further amended--
       (1) in paragraph (76), by striking at the end ``and'';
       (2) in paragraph (77), by striking at the end the period 
     and inserting ``; and''; and
       (3) by inserting after paragraph (77) the following new 
     paragraph:
       ``(78) provide that the State agency described in paragraph 
     (9) exclude, with respect to a period, any individual or 
     entity from participation in the program under the State plan 
     if such individual or entity owns, controls, or manages an 
     entity that (or if such entity is owned, controlled, or 
     managed by an individual or entity that)--
       ``(A) has unpaid overpayments under this title during such 
     period determined by the Secretary or the State agency to be 
     delinquent;
       ``(B) is suspended or excluded from participation under or 
     whose participation is terminated under this title during 
     such period; or
       ``(C) is affiliated with an individual or entity that has 
     been suspended or excluded from participation under this 
     title or whose participation is terminated under this title 
     during such period.''.
       (b) Child Health Plan Requirement.--Section 2107(e)(1)(A) 
     of such Act (42 U.S.C. 1397gg(e)(1)(A)), as amended by 
     section 1756(b), is amended by striking ``section 
     1902(a)(39)'' and inserting ``sections 1902(a)(39) and 
     1902(a)(78)''.
       (c) Effective Date.--Except as provided in section 1790, 
     the amendments made by this section shall apply to services 
     furnished on or after January 1, 2011, without regard to 
     whether or not final regulations to carry out such amendments 
     have been promulgated by such date.

     SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF DATA 
                   ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE.

       Section 1903(r)(1)(F) of the Social Security Act (42 U.S.C. 
     1396b(r)(1)(F)) is amended by inserting after ``necessary'' 
     the following: ``and including, for data submitted to the 
     Secretary on or after July 1, 2010, data elements from the 
     automated data system that the Secretary determines to be 
     necessary for detection of waste, fraud, and abuse''.

     SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE 
                   PAYEES REQUIRED TO REGISTER UNDER MEDICAID.

       (a) In General.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 42 U.S.C. 1396a(a)), as amended by sections 
     1631(b), 1703(a), 1729, 1753, and 1757(a), is further 
     amended--
       (1) in paragraph (77); by striking at the end ``and'';
       (2) in paragraph (78), by striking the period at the end 
     and inserting ``and''; and
       (3) by inserting after paragraph (78) the following new 
     paragraph:
       ``(79) provide that any agent, clearinghouse, or other 
     alternate payee that submits claims on behalf of a health 
     care provider must register with the State and the Secretary 
     in a form and manner specified by the Secretary under section 
     1866(j)(1)(D).''.
       (b) Denial of Payment.--Section 1903(i) of such Act (42 
     U.S.C. 1396b(i)), as amended by section 1751, is amended--
       (1) by striking ``or'' at the end of paragraph (24);
       (2) by striking the period at the end of paragraph (25) and 
     inserting ``; or''; and
       (3) by inserting after paragraph (25) the following new 
     paragraph:
       ``(26) with respect to any amount paid to a billing agent, 
     clearinghouse, or other alternate payee that is not 
     registered with the State and the Secretary as required under 
     section 1902(a)(79).''.
       (c) Effective Date.--Except as provided in section 1790, 
     the amendments made by this section shall apply to claims 
     submitted on or after January 1, 2012, without regard to 
     whether or not final regulations to carry out such amendments 
     have been promulgated by such date.

     SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED 
                   MISCONDUCT.

       (a) In General.--Section 1903(i) of the Social Security Act 
     (42 U.S.C. 1396b(i)), as amended by sections 1751(a) and 
     1759(b), is amended--
       (1) by striking ``or'' at the end of paragraph (25);
       (2) by striking the period at the end of paragraph (26) and 
     inserting ``; or''; and
       (3) by inserting after paragraph (26) the following new 
     paragraph:
       ``(27) with respect to any amount expended--
       ``(A) on litigation in which a court imposes sanctions on 
     the State, its employees, or its counsel for litigation-
     related misconduct; or
       ``(B) to reimburse (or otherwise compensate) a managed care 
     entity for payment of legal expenses associated with any 
     action in which a court imposes sanctions on the managed care 
     entity for litigation-related misconduct.''.
       (b) Effective Date.--The amendments made by subsection (a) 
     shall apply to amounts expended on or after January 1, 2010.

     SEC. 1761. MANDATORY STATE USE OF NATIONAL CORRECT CODING 
                   INITIATIVE.

       Section 1903(r) of the Social Security Act (42 U.S.C. 
     1396b(r)) is amended--
       (1) in paragraph (1)(B)--
       (A) in clause (ii), by striking ``and'' at the end;
       (B) in clause (iii), by adding ``and'' at the end; and
       (C) by adding at the end the following new clause:
       ``(iv) effective for claims filed on or after October 1, 
     2010, incorporate compatible methodologies of the National 
     Correct Coding Initiative administered by the Secretary (or 
     any successor initiative to promote correct coding and to 
     control improper coding leading to inappropriate payment) and 
     such other methodologies of that Initiative (or such other 
     national correct coding methodologies) as the Secretary 
     identifies in accordance with paragraph (4);''; and
       (2) by adding at the end the following new paragraph:
       ``(4) Not later than September 1, 2010, the Secretary shall 
     do the following:
       ``(A) Identify those methodologies of the National Correct 
     Coding Initiative administered by the Secretary (or any 
     successor initiative to promote correct coding and to control 
     improper coding leading to inappropriate payment) which are 
     compatible to claims filed under this title.
       ``(B) Identify those methodologies of such Initiative (or 
     such other national correct coding methodologies) that should 
     be incorporated into claims filed under this title with 
     respect to items or services for which States provide medical 
     assistance under this title and no national correct coding 
     methodologies have been established under such Initiative 
     with respect to title XVIII.
       ``(C) Notify States of--
       ``(i) the methodologies identified under subparagraphs (A) 
     and (B) (and of any other national correct coding 
     methodologies identified under subparagraph (B)); and
       ``(ii) how States are to incorporate such methodologies 
     into claims filed under this title.
       ``(D) Submit a report to Congress that includes the notice 
     to States under subparagraph (C) and an analysis supporting 
     the identification of the methodologies made under 
     subparagraphs (A) and (B).''.

                Subtitle G--Payments to the Territories

     SEC. 1771. PAYMENT TO TERRITORIES.

       (a) Increase in Cap.--Section 1108 of the Social Security 
     Act (42 U.S.C. 1308) is amended--
       (1) in subsection (f), by striking ``subsection (g)'' and 
     inserting ``subsections (g) and (h)'';
       (2) in subsection (g)(1), by striking ``With respect to'' 
     and inserting ``Subject to subsection (h), with respect to''; 
     and
       (3) by adding at the end the following new subsection:
       ``(h) Additional Increase for Fiscal Years 2011 Through 
     2019.--Subject to section 347(b)(1) of the Affordable Health 
     Care for America Act, with respect to fiscal years 2011 
     through 2019, the amounts otherwise determined under 
     subsections (f) and (g) for Puerto Rico, the Virgin Islands, 
     Guam, the Northern Mariana Islands and American Samoa shall 
     be increased by the following amounts:
       ``(1) For Puerto Rico, for fiscal year 2011, $727,600,000; 
     for fiscal year 2012, $775,000,000; for fiscal year 2013, 
     $850,000,000; for fiscal year 2014, $925,000,000; for fiscal 
     year 2015, $1,000,000,000; for fiscal year 2016, 
     $1,075,000,000; for fiscal year 2017, $1,150,000,000; for 
     fiscal year 2018, $1,225,000,000; and for fiscal year 2019, 
     $1,396,400,000.
       ``(2) For the Virgin Islands, for fiscal year 2011, 
     $34,000,000; for fiscal year 2012, $37,000,000; for fiscal 
     year 2013, $40,000,000; for fiscal year 2014, $43,000,000; 
     for fiscal year 2015, $46,000,000; for fiscal year 2016, 
     $49,000,000; for fiscal year 2017, $52,000,000; for fiscal 
     year 2018, $55,000,000; and for fiscal year 2019, 
     $58,000,000.
       ``(3) For Guam, for fiscal year 2011, $34,000,000; for 
     fiscal year 2012, $37,000,000; for fiscal year 2013, 
     $40,000,000; for fiscal year 2014, $43,000,000; for fiscal 
     year 2015, $46,000,000; for fiscal year 2016, $49,000,000; 
     for fiscal year 2017, $52,000,000; for fiscal year 2018, 
     $55,000,000; and for fiscal year 2019, $58,000,000.
       ``(4) For the Northern Mariana Islands, for fiscal year 
     2011, $13,500,000; fiscal year 2012, $14,500,000; for fiscal 
     year 2013, $15,500,000; for fiscal year 2014, $16,500,000; 
     for fiscal year 2015, $17,500,000; for fiscal year 2016, 
     $18,500,000; for fiscal year 2017, $19,500,000; for

[[Page 27337]]

     fiscal year 2018, $21,000,000; and for fiscal year 2019, 
     $22,000,000.
       ``(5) For American Samoa, fiscal year 2011, $22,000,000; 
     fiscal year 2012, $23,687,500; for fiscal year 2013, 
     $24,687,500; for fiscal year 2014, $25,687,500; for fiscal 
     year 2015, $26,687,500; for fiscal year 2016, $27,687,500; 
     for fiscal year 2017, $28,687,500; for fiscal year 2018, 
     $29,687,500; and for fiscal year 2019, $30,687,500.''.
       (b) Report on Achieving Medicaid Parity Payments Beginning 
     With Fiscal Year 2020.--
       (1) In general.--Not later than October 1, 2013, the 
     Secretary of Health and Human Services shall submit to 
     Congress a report that details a plan for the transition of 
     each territory to full parity in Medicaid with the 50 States 
     and the District of Columbia in fiscal year 2020 by modifying 
     their existing Medicaid programs and outlining actions the 
     Secretary and the governments of each territory must take by 
     fiscal year 2020 to ensure parity in financing. Such report 
     shall include what the Federal medical assistance percentages 
     would be for each territory if the formula applicable to the 
     50 States were applied. Such report shall also include any 
     recommendations that the Secretary may have as to whether the 
     mandatory ceiling amounts for each territory provided for in 
     section 1108 of the Social Security Act (42 U.S.C. 1308) 
     should be increased any time before fiscal year 2020 due to 
     any factors that the Secretary deems relevant.
       (2) Per capita data.--As part of such report the Secretary 
     shall include information about per capita income data that 
     could be used to calculate Federal medical assistance 
     percentages under section 1905(b) of the Social Security Act, 
     under section 1108(a)(8)(B) of such Act, for each territory 
     on how such data differ from the per capita income data used 
     to promulgate Federal medical assistance percentages for the 
     50 States. The report under this subsection shall include 
     recommendations on how the Federal medical assistance 
     percentages can be calculated for the territories beginning 
     in fiscal year 2020 to ensure parity with the 50 States.
       (3) Subsequent reports.--The Secretary shall submit 
     subsequent reports to Congress in 2015, 2017, and 2019 
     detailing the progress that the Secretary and the governments 
     of each territory have made in fulfilling the actions 
     outlined in the plan submitted under paragraph (1).
       (c) Application of FMAP for Additional Funds.--Section 
     1905(b) of such Act (42 U.S.C. 1396d(b)) is amended by adding 
     at the end the following sentence: ``Notwithstanding the 
     first sentence of this subsection and any other provision of 
     law, for fiscal years 2011 through 2019, the Federal medical 
     assistance percentage for Puerto Rico, the Virgin Islands, 
     Guam, the Northern Mariana Islands, and American Samoa shall 
     be the highest Federal medical assistance percentage 
     applicable to any of the 50 States or the District of 
     Columbia for the fiscal year involved, taking into account 
     the application of subsections (a) and (b)(1) of section 5001 
     of division B of the American Recovery and Reinvestment Act 
     of 2009 (Public Law 111-5) to such States and the District 
     for calendar quarters during such fiscal years for which such 
     subsections apply.''.
       (d) Waivers.--
       (1) In general.--Section 1902(j) of the Social Security Act 
     (42 U.S.C. 1396a(j)) is amended--
       (A) by striking ``American Samoa and the Northern Mariana 
     Islands'' and inserting ``Puerto Rico, the Virgin Islands, 
     Guam, the Northern Mariana Islands, and American Samoa''; and
       (B) by striking ``American Samoa or the Northern Mariana 
     Islands'' and inserting ``Puerto Rico, the Virgin Islands, 
     Guam, the Northern Mariana Islands, or American Samoa''.
       (2) Effective date.--The amendments made by paragraph (1) 
     shall apply beginning with fiscal year 2011.
       (e) Technical Assistance.--The Secretary shall provide 
     nonmonetary technical assistance to the governments of Puerto 
     Rico, the Virgin Islands, Guam, the Northern Mariana Islands, 
     and American Samoa in upgrading their existing computer 
     systems in order to anticipate meeting reporting requirements 
     necessary to implement the plan contained in the report under 
     subsection (b)(1).

                       Subtitle H--Miscellaneous

     SEC. 1781. TECHNICAL CORRECTIONS.

       (a) Technical Correction to Section 1144 of the Social 
     Security Act.--The first sentence of section 1144(c)(3) of 
     the Social Security Act (42 U.S.C. 1320b--14(c)(3)) is 
     amended--
       (1) by striking ``transmittal''; and
       (2) by inserting before the period the following: ``as 
     specified in section 1935(a)(4)''.
       (b) Clarifying Amendment to Section 1935 of the Social 
     Security Act.--Section 1935(a)(4) of the Social Security Act 
     (42 U.S.C. 1396u--5(a)(4)), as amended by section 113(b) of 
     Public Law 110-275, is amended--
       (1) by striking the second sentence;
       (2) by redesignating the first sentence as a subparagraph 
     (A) with appropriate indentation and with the following 
     heading: ``In general.--'';
       (3) by adding at the end the following subparagraphs:
       ``(B) Furnishing medical assistance with reasonable 
     promptness.--For the purpose of a State's obligation under 
     section 1902(a)(8) to furnish medical assistance with 
     reasonable promptness, the date of the electronic 
     transmission of low-income subsidy program data, as described 
     in section 1144(c), from the Commissioner of Social Security 
     to the State Medicaid Agency, shall constitute the date of 
     filing of such application for benefits under the Medicare 
     Savings Program.
       ``(C) Determining availability of medical assistance.--For 
     the purpose of determining when medical assistance will be 
     made available, the State shall consider the date of the 
     individual's application for the low income subsidy program 
     to constitute the date of filing for benefits under the 
     Medicare Savings Program.''.
       (c) Effective Date Relating to Medicaid Agency 
     Consideration of Low-income Subsidy Application and Data 
     Transmittal.--The amendments made by subsections (a) and (b) 
     shall be effective as if included in the enactment of section 
     113(b) of Public Law 110-275.
       (d) Technical Correction to Section 605 of CHIPRA.--Section 
     605 of the Children's Health Insurance Program 
     Reauthorization Act of 2009 (Public Law 111-3) is amended by 
     striking ``legal residents'' and inserting ``lawfully 
     residing in the United States''.
       (e) Technical Correction to Section 1905 of the Social 
     Security Act.--Section 1905(a) of the Social Security Act (42 
     U.S.C. 1396d(a)) is amended by inserting ``or the care and 
     services themselves, or both'' before ``(if provided in or 
     after''.
       (f) Clarifying Amendment to Section 1115 of the Social 
     Security Act.--Section 1115(a) of the Social Security Act (42 
     U.S.C. 1315(a)) is amended by adding at the end the 
     following: ``If an experimental, pilot, or demonstration 
     project that relates to title XIX is approved pursuant to any 
     part of this subsection, such project shall be treated as 
     part of the State plan, all medical assistance provided on 
     behalf of any individuals affected by such project shall be 
     medical assistance provided under the State plan, and all 
     provisions of this Act not explicitly waived in approving 
     such project shall remain fully applicable to all individuals 
     receiving benefits under the State plan.''.

     SEC. 1782. EXTENSION OF QI PROGRAM.

       (a) In General.--Section 1902(a)(10)(E)(iv) of the Social 
     Security Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended--
       (1) by striking ``sections 1933 and'' and by inserting 
     ``section''; and
       (2) by striking ``December 2010'' and inserting ``December 
     2012''.
       (b) Elimination of Funding Limitation.--
       (1) In general.--Section 1933 of such Act (42 U.S.C. 1396u-
     3) is amended--
       (A) in subsection (a), by striking ``who are selected to 
     receive such assistance under subsection (b)'';
       (B) by striking subsections (b), (c), (e), and (g);
       (C) in subsection (d), by striking ``furnished in a State'' 
     and all that follows and inserting ``the Federal medical 
     assistance percentage shall be equal to 100 percent.''; and
       (D) by redesignating subsections (d) and (f) as subsections 
     (b) and (c), respectively.
       (2) Conforming amendment.--Section 1905(b) of such Act (42 
     U.S.C. 1396d(b)) is amended by striking ``1933(d)'' and 
     inserting ``1933(b)''.
       (3) Effective date.--The amendments made by paragraph (1) 
     shall take effect on January 1, 2011.

     SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION.

       (a) In General.--Section 1902(a) of the Social Security Act 
     (42 U.S.C. 1396a(a)), as amended by sections 1631(b), 
     1703(a), 1729, 1753, 1757(a), 1759(a), and 1907(b), is 
     amended--
       (1) by striking ``and'' at the end of paragraph (79);
       (2) by striking the period at the end of paragraph (80) and 
     inserting ``; and''; and
       (3) by inserting after paragraph (80) the following new 
     paragraph:
       ``(81) provide that the State will establish and maintain 
     laws, in accordance with the requirements of section 1921A, 
     to require disclosure of information on hospital charges and 
     quality and to make such information available to the public 
     and the Secretary.''; and
       (4) by inserting after section 1921 the following new 
     section:


                     ``hospital price transparency

       ``Sec. 1921A.  (a) In General.--The requirements referred 
     to in section 1902(a)(81) are that the laws of a State must--
       ``(1) require reporting to the State (or its agent) by each 
     hospital located therein, of information on,--
       ``(A) the charges for the most common inpatient and 
     outpatient hospital services;
       ``(B) the Medicare and Medicaid reimbursement amount for 
     such services; and
       ``(C) if the hospitals allows for or provides reduced 
     charges for individuals based on financial need, the factors 
     considered in making determinations for reductions in 
     charges, including any formula for such determination and the 
     contact information for the specific department of a hospital 
     that responds to such inquiries;
       ``(2) provide for notice to individuals seeking or 
     requiring such services of the availability of information on 
     charges described in paragraph (1);

[[Page 27338]]

       ``(3) provide for timely access to such information, 
     including at least through an Internet website, by 
     individuals seeking or requiring such services; and
       ``(4) provide for timely access to information regarding 
     the quality of care at each hospital made publicly available 
     in accordance with section 501 of the Medicare Prescription 
     Drug, Improvement, and Modernization Act of 2003 (Public Law 
     108-173), section 1139A, or section 1139B.
     The Secretary shall consult with stakeholders (including 
     those entities in section 1808(d)(6) and the National 
     Governors Association) through a formal process to obtain 
     guidance prior to issuing implementing policies under this 
     section.
       ``(b) Hospital Defined.--For purposes of this section, the 
     term `hospital' means an institution that meets the 
     requirements of paragraphs (1) and (7) of section 1861(e) and 
     includes those to which section 1820(c) applies.''.
       (b) Effective Date; Administration.--
       (1) In general.--Except as provided in paragraphs (2)(B) 
     and section 1790, the amendments made by subsection (a) shall 
     take effect on October 1, 2010.
       (2) Existing programs.--
       (A) In general.--The Secretary of Health and Human Services 
     shall establish a process by which a State with an existing 
     program may certify to the Secretary that its program 
     satisfies the requirements of section 1921A of the Social 
     Security Act, as inserted by subsection (a).
       (B) 2-year period to become in compliance.--States that, as 
     of the date of the enactment of this Act, administer hospital 
     price transparency policies that do not meet such 
     requirements shall have 2 years from such date to make 
     necessary modifications to come into compliance and shall not 
     be regarded as failing to comply with such requirements 
     during such 2-year period.

     SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION.

       (a) Report on Nursing Facility Payment Policies.--Section 
     1900(b) of the Social Security Act (42 U.S.C. 1396(b)) is 
     amended by adding at the end the following new paragraph:
       ``(10) Reports on special topics on payment policies.--
       ``(A) Nursing facility payment policies.--Not later than 
     January 1, 2012, the Commission shall submit to Congress a 
     report on nursing facility payment policies under Medicaid 
     that includes--
       ``(i) information on the difference between the amount paid 
     by each State to nursing facilities in such State under the 
     Medicaid program under this title and the cost to such 
     facilities of providing efficient quality care to Medicaid 
     eligible individuals;
       ``(ii) an evaluation of patient outcomes and quality as a 
     result of the supplemental payments under section 1745(b) of 
     the Affordable Health Care for America Act; and
       ``(iii) whether adjustments should be made under the 
     Medicaid program to the rates that States pay skilled nursing 
     facilities to ensure that such rates are sufficient to 
     provide efficient quality care to Medicaid eligible 
     individuals.''.
       (b) Pediatric Subspecialist Payment Policies.--Section 
     1900(b)(10) of the Social Security Act, as added by 
     subsection (a) is amended by adding at the end the following 
     new subparagraph:
       ``(B) Pediatric subspecialist payment policies.--Not later 
     than January 1, 2011, the Commission shall submit to Congress 
     a report on payment policies for pediatric subspecialist 
     services under Medicaid that includes--
       ``(i) a comprehensive review of each State's Medicaid 
     payment rates for inpatient and outpatient pediatric 
     speciality services;
       ``(ii) a comparison, on a State-by-State basis, of the 
     rates under clause (i) to Medicare payments for similar 
     services;
       ``(iii) information on any limitations in patient access to 
     pediatric speciality care, such as delays in receiving care 
     or wait times for receiving care;
       ``(iv) an analysis of the extent to which low Medicaid 
     payment rates in any State contributes to limits in access to 
     pediatric subspecialty services in such State; and
       ``(v) recommendations to ameliorate any problems found with 
     such payment rates or with access to such services.''.
       (c) Additional Amendments.--
       (1) Commission status.--Section 1900(a) of the Social 
     Security Act is amended by inserting ``as an agency of 
     Congress'' after ``established''.
       (2) Expansion of scope.--Section 1900(b)(1)(A) of the 
     Social Security Act is amended by striking ``children's 
     access'' and inserting ``access by low-income children and 
     other eligible individuals''.
       (3) Change in report deadlines.--Subparagraphs (C) and (D) 
     of section 1900(b)(1) of such Act are amended by striking 
     ``2010'' and inserting ``2011'' each place it appears.
       (4) Report in health reform.--Section 1900(b)(2) of such 
     Act is amended--
       (A) in subparagraph (A)(i), by striking ``skilled'';
       (B) by striking subparagraph (B);
       (C) by redesignating subparagraph (C) as subparagraph (B); 
     and
       (D) by adding at the end the following new subparagraph:
       ``(C) Implementation of health reform.--The implementation 
     of the provisions of the Affordable Health Care for America 
     Act that relate to Medicaid or CHIP by the Secretary, the 
     Health Choices Commissioner, and the States, including the 
     effect of such implementation on the access to needed health 
     care items and services by low-income individuals and 
     families.''.
       (5) Clarification of membership.--Section 1900(c)(2)(B) of 
     such Act is amended by striking ``consumers'' and inserting 
     ``individuals''.
       (6) Authorization of appropriations.--
       (A) Current authorization.--Section 1900(f)(2) of such Act 
     is amended--
       (i) in the heading, by inserting ``of appropriations prior 
     to 2010'' after ``Authorization''; and
       (ii) by striking ``There are'' and inserting ``Prior to 
     January 1, 2010, there are''
       (B) Future authorization.--Section 1900(f) of such Act is 
     further amended by adding at the end the following new 
     paragraph: after the period the following:
       ``(3) Authorization of appropriations for 2010.--Beginning 
     on January 1, 2010, there is authorized to be appropriated 
     $11,800,000 to carry out the provisions of this section. Such 
     funds shall remain available until expended.''.

     SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID AND CHIP 
                   ELIGIBLE INDIVIDUALS.

       (a) In General.--Not later than 12 months after date of 
     enactment of this Act, the Secretary of Health and Human 
     Services shall issue guidance regarding standards and best 
     practices for conducting outreach to inform eligible 
     individuals about healthcare coverage under Medicaid under 
     title XIX of the Social Security Act or for child health 
     assistance under CHIP under title XXI of such Act, providing 
     assistance to such individuals for enrollment in applicable 
     programs, and establishing methods or procedures for 
     eliminating application and enrollment barriers. Such 
     guidance shall include provisions to ensure that outreach, 
     enrollment assistance, and administrative simplification 
     efforts are targeted specifically to vulnerable populations 
     such as children, unaccompanied homeless youth, victims of 
     abuse or trauma, individuals with mental health or substance 
     related disorders, and individuals with HIV/AIDS. Guidance 
     issued pursuant to this section relating to methods to 
     increase outreach and enrollment provided for under titles 
     XIX and XXI of the Social Security Act shall specifically 
     target such vulnerable and underserved populations and shall 
     include, but not be limited to, guidance on outstationing of 
     eligibility workers, express lane eligibility, residence 
     requirements, documentation of income and assets, presumptive 
     eligibility, continuous eligibility, and automatic renewal.
       (b) Implementation.--In implementing the requirements under 
     subsection (a), the Secretary may use such authorities as are 
     available under law and may work with such entities as the 
     Secretary deems appropriate to facilitate effective 
     implementation of such programs. Not later than 2 years after 
     the enactment of this Act and annually thereafter, the 
     Secretary shall review and report to Congress on progress in 
     implementing targeted outreach, application and enrollment 
     assistance, and administrative simplification methods for 
     such vulnerable and underserved populations as are specified 
     in subsection (a).

     SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND CHIP PAYMENT 
                   FOR UNDOCUMENTED ALIENS.

       Nothing in this title shall change current prohibitions 
     against Federal Medicaid and CHIP payments under titles XIX 
     and XXI of the Social Security Act on behalf of individuals 
     who are not lawfully present in the United States.

     SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION OF 
                   EMERGENCY MEDICAL CONDITIONS BY INSTITUTIONS 
                   FOR MENTAL DISEASES.

       (a) Authority To Conduct Demonstration Project.--The 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall establish a 
     demonstration project under which an eligible State (as 
     described in subsection (c)) shall provide reimbursement 
     under the State Medicaid plan under title XIX of the Social 
     Security Act to an institution for mental diseases that is 
     subject to the requirements of section 1867 of the Social 
     Security Act (42 U.S.C. 1395dd) for the provision of medical 
     assistance available under such plan to an individual who--
       (1) has attained age 21, but has not attained age 65;
       (2) is eligible for medical assistance under such plan; and
       (3) requires such medical assistance to stabilize an 
     emergency medical condition.
       (b) In-stay Review.--The Secretary shall establish a 
     mechanism for in-stay review to determine whether or not the 
     patient has been stabilized (as defined in subsection 
     (h)(5)). This mechanism shall commence before the third day 
     of the inpatient stay. States participating in the 
     demonstration project may manage the provision of these 
     benefits under the project through utilization review, 
     authorization, or management practices, or the application of 
     medical necessity and appropriateness criteria applicable to 
     behavioral health.

[[Page 27339]]

       (c) Eligible State Defined.--
       (1) Application.--Upon approval of an application submitted 
     by a State described in paragraph (2), the State shall be an 
     eligible State for purposes of conducting a demonstration 
     project under this section.
       (2) State described.--States shall be selected by the 
     Secretary in a manner so as to provide geographic diversity 
     on the basis of the application to conduct a demonstration 
     project under this section submitted by such States.
       (d) Length of Demonstration Project.--The demonstration 
     project established under this section shall be conducted for 
     a period of 3 consecutive years.
       (e) Limitations on Federal Funding.--
       (1) Appropriation.--
       (A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to carry out 
     this section, $75,000,000 for fiscal year 2010.
       (B) Budget authority.--Subparagraph (A) constitutes budget 
     authority in advance of appropriations Act and represents the 
     obligation of the Federal Government to provide for the 
     payment of the amounts appropriated under that subparagraph.
       (2) 3-year availability.--Funds appropriated under 
     paragraph (1) shall remain available for obligation through 
     December 31, 2012.
       (3) Limitation on payments.--In no case may--
       (A) the aggregate amount of payments made by the Secretary 
     to eligible States under this section exceed $75,000,000; or
       (B) payments be provided by the Secretary under this 
     section after December 31, 2012.
       (4) Funds allocated to states.--The Secretary shall 
     allocate funds to eligible States based on their applications 
     and the availability of funds.
       (5) Payments to states.--The Secretary shall pay to each 
     eligible State, from its allocation under paragraph (4), an 
     amount each quarter equal to the Federal medical assistance 
     percentage of expenditures in the quarter for medical 
     assistance described in subsection (a).
       (f) Reports.--
       (1) Annual progress reports.--The Secretary shall submit 
     annual reports to Congress on the progress of the 
     demonstration project conducted under this section.
       (2) Final report and recommendation.--An evaluation shall 
     be conducted of the demonstration project's impact on the 
     functioning of the health and mental health service system 
     and on individuals enrolled in the Medicaid program. This 
     evaluation shall include collection of baseline data for one-
     year prior to the initiation of the demonstration project as 
     well as collection of data from matched comparison states not 
     participating in the demonstration. The evaluation measures 
     shall include the following:
       (A) A determination, by State, as to whether the 
     demonstration project resulted in increased access to 
     inpatient mental health services under the Medicaid program 
     and whether average length of stays were longer (or shorter) 
     for individuals admitted under the demonstration project 
     compared with individuals otherwise admitted in comparison 
     sites.
       (B) An analysis, by State, regarding whether the 
     demonstration project produced a significant reduction in 
     emergency room visits for individuals eligible for assistance 
     under the Medicaid program or in the duration of emergency 
     room lengths of stay.
       (C) An assessment of discharge planning by participating 
     hospitals that ensures access to further (non-emergency) 
     inpatient or residential care as well as continuity of care 
     for those discharged to outpatient care.
       (D) An assessment of the impact of the demonstration 
     project on the costs of the full range of mental health 
     services (including inpatient, emergency and ambulatory care) 
     under the plan as contrasted with the comparison areas.
       (E) Data on the percentage of consumers with Medicaid 
     coverage who are admitted to inpatient facilities as a result 
     of the demonstration project as compared to those admitted to 
     these same facilities through other means.
       (F) A recommendation regarding whether the demonstration 
     project should be continued after December 31, 2012, and 
     expanded on a national basis.
       (g) Waiver Authority.--
       (1) In general.--The Secretary shall waive the limitation 
     of subdivision (B) following paragraph (28) of section 
     1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
     (relating to limitations on payments for care or services for 
     individuals under 65 years of age who are patients in an 
     institution for mental diseases) for purposes of carrying out 
     the demonstration project under this section.
       (2) Limited other waiver authority.--The Secretary may 
     waive other requirements of title XIX of the Social Security 
     Act (including the requirements of sections 1902(a)(1) 
     (relating to statewideness) and 1902(1)(10)(B) (relating to 
     comparability)) only to extent necessary to carry out the 
     demonstration project under this section.
       (h) Definitions.--In this section:
       (1) Emergency medical condition.--The term ``emergency 
     medical condition'' means, with respect to an individual, an 
     individual who expresses suicidal or homicidal thoughts or 
     gestures, if determined dangerous to self or others.
       (2) Federal medical assistance percentage.--The term 
     ``Federal medical assistance percentage'' has the meaning 
     given that term with respect to a State under section 1905(b) 
     of the Social Security Act (42 U.S.C. 1396d(b)).
       (3) Institution for mental diseases.--The term 
     ``institution for mental diseases'' has the meaning given to 
     that term in section 1905(i) of the Social Security Act (42 
     U.S.C. 1396d(i)).
       (4) Medical assistance.--The term ``medical assistance'' 
     has the meaning given to that term in section 1905(a) of the 
     Social Security Act (42 U.S.C. 1396d(a)).
       (5) Stabilized.--The term ``stabilized'' means, with 
     respect to an individual, that the emergency medical 
     condition no longer exists with respect to the individual and 
     the individual is no longer dangerous to self or others.
       (6) State.--The term ``State'' has the meaning given that 
     term for purposes of title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).

     SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT FUND.

       Section 1941(b)(1) of the Social Security Act (42 U.S.C. 
     1396w-1(b)(1)) is amended by striking ``from the Fund'' and 
     all that follows and inserting ``from the Fund, only such 
     amounts as may be appropriated or otherwise made available by 
     law.''.

     SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS.

       Section 1903(b)(4) of the Social Security Act (42 U.S.C. 
     1396b(b)(4)) is amended--
       (1) in the matter before subparagraph (A), by inserting 
     after ``respect to the broker'' the following: ``(or, in the 
     case of subparagraph (A) and subparagraph (B)(i), if the 
     Inspector General of Department of Health and Human Services 
     finds that the broker has established and maintains 
     procedures to ensure the independence of its enrollment 
     activities from the interests of any managed care entity or 
     provider)''; and
       (2) in subparagraph (B)--
       (A) by inserting ``(i)'' after ``either''; and
       (B) by inserting ``(ii)'' after ``health care provider 
     or''.

     SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGISLATION.

       In the case of a State plan for medical assistance under 
     title XIX of the Social Security Act which the Secretary of 
     Health and Human Services determines requires State 
     legislation (other than legislation appropriating funds) in 
     order for the plan to meet an additional requirement imposed 
     by an amendment made by this title, the State plan shall not 
     be regarded as failing to comply with the requirements of 
     such title XIX solely on the basis of its failure to meet 
     this additional requirement before the first day of the first 
     calendar quarter beginning after the close of the first 
     regular session of the State legislature that begins after 
     the date of the enactment of this Act. For purposes of the 
     previous sentence, in the case of a State that has a 2-year 
     legislative session, each year of such session shall be 
     deemed to be a separate regular session of the State 
     legislature.

                 TITLE VIII--REVENUE-RELATED PROVISIONS

     SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF 
                   INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE 
                   LOW-INCOME ASSISTANCE UNDER THE MEDICARE 
                   PRESCRIPTION DRUG PROGRAM TO ASSIST SOCIAL 
                   SECURITY ADMINISTRATION'S OUTREACH TO ELIGIBLE 
                   INDIVIDUALS.

       (a) In General.--Paragraph (19) of section 6103(l) of the 
     Internal Revenue Code of 1986 is amended to read as follows:
       ``(19) Disclosures to facilitate identification of 
     individuals likely to be ineligible for low-income subsidies 
     under medicare prescription drug program to assist social 
     security administration's outreach to eligible individuals.--
       ``(A) In general.--Upon written request from the 
     Commissioner of Social Security, the following return 
     information (including such information disclosed to the 
     Social Security Administration under paragraph (1) or (5)) 
     shall be disclosed to officers and employees of the Social 
     Security Administration, with respect to any taxpayer 
     identified by the Commissioner of Social Security--
       ``(i) return information for the applicable year from 
     returns with respect to wages (as defined in section 3121(a) 
     or 3401(a)) and payments of retirement income (as described 
     in paragraph (1) of this subsection),
       ``(ii) unearned income information and income information 
     of the taxpayer from partnerships, trusts, estates, and 
     subchapter S corporations for the applicable year,
       ``(iii) if the individual filed an income tax return for 
     the applicable year, the filing status, number of dependents, 
     income from farming, and income from self-employment, on such 
     return,
       ``(iv) if the individual is a married individual filing a 
     separate return for the applicable year, the social security 
     number (if reasonably available) of the spouse on such 
     return,
       ``(v) if the individual files a joint return for the 
     applicable year, the social security number, unearned income 
     information, and income information from partnerships, 
     trusts,

[[Page 27340]]

     estates, and subchapter S corporations of the individual's 
     spouse on such return, and
       ``(vi) such other return information relating to the 
     individual (or the individual's spouse in the case of a joint 
     return) as is prescribed by the Secretary by regulation as 
     might indicate that the individual is likely to be ineligible 
     for a low-income prescription drug subsidy under section 
     1860D-14 of the Social Security Act.
       ``(B) Applicable year.--For the purposes of this paragraph, 
     the term `applicable year' means the most recent taxable year 
     for which information is available in the Internal Revenue 
     Service's taxpayer information records.
       ``(C) Restriction on individuals for whom disclosure may be 
     requested.--The Commissioner of Social Security shall request 
     information under this paragraph only with respect to--
       ``(i) individuals the Social Security Administration has 
     identified, using all other reasonably available information, 
     as likely to be eligible for a low-income prescription drug 
     subsidy under section 1860D-14 of the Social Security Act and 
     who have not applied for such subsidy, and
       ``(ii) any individual the Social Security Administration 
     has identified as a spouse of an individual described in 
     clause (i).
       ``(D) Restriction on use of disclosed information.--Return 
     information disclosed under this paragraph may be used only 
     by officers and employees of the Social Security 
     Administration solely for purposes of identifying individuals 
     likely to be ineligible for a low-income prescription drug 
     subsidy under section 1860D-14 of the Social Security Act for 
     use in outreach efforts under section 1144 of the Social 
     Security Act.''.
       (b) Safeguards.--Paragraph (4) of section 6103(p) of such 
     Code is amended--
       (1) by striking ``(19),'' each place it appears, and
       (2) by striking ``or (17)'' each place it appears and 
     inserting ``(17), or (19)''.
       (c) Conforming Amendment.--Paragraph (3) of section 6103(a) 
     of such Code is amended by striking ``(19),''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to disclosures made after the date which is 12 
     months after the date of the enactment of this Act.

     SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; 
                   FINANCING FOR TRUST FUND.

       (a) Establishment of Trust Fund.--
       (1) In general.--Subchapter A of chapter 98 of the Internal 
     Revenue Code of 1986 (relating to trust fund code) is amended 
     by adding at the end the following new section:

     ``SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH 
                   TRUST FUND.

       ``(a) Creation of Trust Fund.--There is established in the 
     Treasury of the United States a trust fund to be known as the 
     `Health Care Comparative Effectiveness Research Trust Fund' 
     (hereinafter in this section referred to as the `CERTF'), 
     consisting of such amounts as may be appropriated or credited 
     to such Trust Fund as provided in this section and section 
     9602(b).
       ``(b) Transfers to Fund.--
       ``(1) In general.--There are hereby appropriated to the 
     Trust Fund the following:
       ``(A) For fiscal year 2010, $90,000,000.
       ``(B) For fiscal year 2011, $100,000,000.
       ``(C) For fiscal year 2012, $110,000,000.
       ``(D) For each fiscal year beginning with fiscal year 
     2013--
       ``(i) an amount equivalent to the net revenues received in 
     the Treasury from the fees imposed under subchapter B of 
     chapter 34 (relating to fees on health insurance and self-
     insured plans) for such fiscal year; and
       ``(ii) subject to subsection (c)(2), amounts determined by 
     the Secretary of Health and Human Services to be equivalent 
     to the fair share per capita amount computed under subsection 
     (c)(1) for the fiscal year multiplied by the average number 
     of individuals entitled to benefits under part A, or enrolled 
     under part B, of title XVIII of the Social Security Act 
     during such fiscal year.
       ``(2) Administrative provisions.--
       ``(A) Transfers from other trust funds.--The amounts 
     appropriated by subparagraphs (A), (B), (C), and (D)(ii) of 
     paragraph (1) shall be transferred from the Federal Hospital 
     Insurance Trust Fund and from the Federal Supplementary 
     Medical Insurance Trust Fund (established under section 1841 
     of such Act), and from the Medicare Prescription Drug Account 
     within such Trust Fund, in proportion (as estimated by the 
     Secretary) to the total expenditures during such fiscal year 
     that are made under title XVIII of such Act from the 
     respective trust fund or account.
       ``(B) Appropriations not subject to fiscal year 
     limitation.--The amounts appropriated by paragraph (1) shall 
     not be subject to any fiscal year limitation.
       ``(C) Periodic transfers, estimates, and adjustments.--
     Except as provided in subparagraph (A), the provisions of 
     section 9601 shall apply to the amounts appropriated by 
     paragraph (1).
       ``(c) Fair Share Per Capita Amount.--
       ``(1) Computation.--
       ``(A) In general.--Subject to subparagraph (B), the fair 
     share per capita amount under this paragraph for a fiscal 
     year (beginning with fiscal year 2013) is an amount computed 
     by the Secretary of Health and Human Services for such fiscal 
     year that, when applied under this section and subchapter B 
     of chapter 34 of the Internal Revenue Code of 1986, will 
     result in revenues to the CERTF of $375,000,000 for the 
     fiscal year.
       ``(B) Alternative computation.--
       ``(i) In general.--If the Secretary is unable to compute 
     the fair share per capita amount under subparagraph (A) for a 
     fiscal year, the fair share per capita amount under this 
     paragraph for the fiscal year shall be the default amount 
     determined under clause (ii) for the fiscal year.
       ``(ii) Default amount.--The default amount under this 
     clause for--

       ``(I) fiscal year 2013 is equal to $2; or
       ``(II) a subsequent year is equal to the default amount 
     under this clause for the preceding fiscal year increased by 
     the annual percentage increase in the medical care component 
     of the consumer price index (United States city average) for 
     the 12-month period ending with April of the preceding fiscal 
     year.

     Any amount determined under subclause (II) shall be rounded 
     to the nearest penny.
       ``(2) Limitation on medicare funding.--In no case shall the 
     amount transferred under subsection (b)(4)(B) for any fiscal 
     year exceed $90,000,000.
       ``(d) Expenditures From Fund.--
       ``(1) In general.--Subject to paragraph (2), amounts in the 
     CERTF are available, without the need for further 
     appropriations and without fiscal year limitation, to the 
     Secretary of Health and Human Services to carry out section 
     1181 of the Social Security Act.
       ``(2) Allocation for commission.--The following amounts in 
     the CERTF shall be available, without the need for further 
     appropriations and without fiscal year limitation, to the 
     Commission to carry out the activities of the Comparative 
     Effectiveness Research Commission established under section 
     1181(b) of the Social Security Act:
       ``(A) For fiscal year 2010, $7,000,000.
       ``(B) For fiscal year 2011, $9,000,000.
       ``(C) For each fiscal year beginning with 2012, 2.6 percent 
     of the total amount appropriated to the CERTF under 
     subsection (b) for the fiscal year.
       ``(e) Net Revenues.--For purposes of this section, the term 
     `net revenues' means the amount estimated by the Secretary 
     based on the excess of--
       ``(1) the fees received in the Treasury under subchapter B 
     of chapter 34, over
       ``(2) the decrease in the tax imposed by chapter 1 
     resulting from the fees imposed by such subchapter.''.
       (2) Clerical amendment.--The table of sections for such 
     subchapter A is amended by adding at the end thereof the 
     following new item:

``Sec. 9511. Health Care Comparative Effectiveness Research Trust 
              Fund.''.

       (b) Financing for Fund From Fees on Insured and Self-
     Insured Health Plans.--
       (1) General rule.--Chapter 34 of the Internal Revenue Code 
     of 1986 is amended by adding at the end the following new 
     subchapter:

         ``Subchapter B--Insured and Self-Insured Health Plans

``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.

     ``SEC. 4375. HEALTH INSURANCE.

       ``(a) Imposition of Fee.--There is hereby imposed on each 
     specified health insurance policy for each policy year a fee 
     equal to the fair share per capita amount determined under 
     section 9511(c)(1) multiplied by the average number of lives 
     covered under the policy.
       ``(b) Liability for Fee.--The fee imposed by subsection (a) 
     shall be paid by the issuer of the policy.
       ``(c) Specified Health Insurance Policy.--For purposes of 
     this section:
       ``(1) In general.--Except as otherwise provided in this 
     section, the term `specified health insurance policy' means 
     any accident or health insurance policy issued with respect 
     to individuals residing in the United States.
       ``(2) Exemption for certain policies.--The term `specified 
     health insurance policy' does not include any insurance if 
     substantially all of its coverage is of excepted benefits 
     described in section 9832(c).
       ``(3) Treatment of prepaid health coverage arrangements.--
       ``(A) In general.--In the case of any arrangement described 
     in subparagraph (B)--
       ``(i) such arrangement shall be treated as a specified 
     health insurance policy, and
       ``(ii) the person referred to in such subparagraph shall be 
     treated as the issuer.
       ``(B) Description of arrangements.--An arrangement is 
     described in this subparagraph if under such arrangement 
     fixed payments or premiums are received as consideration for 
     any person's agreement to provide or arrange for the 
     provision of accident or health coverage to residents of the 
     United States, regardless of how such coverage is provided or 
     arranged to be provided.

     ``SEC. 4376. SELF-INSURED HEALTH PLANS.

       ``(a) Imposition of Fee.--In the case of any applicable 
     self-insured health plan for each plan year, there is hereby 
     imposed a fee equal to the fair share per capita amount 
     determined under section 9511(c)(1) multiplied

[[Page 27341]]

     by the average number of lives covered under the plan.
       ``(b) Liability for Fee.--
       ``(1) In general.--The fee imposed by subsection (a) shall 
     be paid by the plan sponsor.
       ``(2) Plan sponsor.--For purposes of paragraph (1) the term 
     `plan sponsor' means--
       ``(A) the employer in the case of a plan established or 
     maintained by a single employer,
       ``(B) the employee organization in the case of a plan 
     established or maintained by an employee organization,
       ``(C) in the case of--
       ``(i) a plan established or maintained by 2 or more 
     employers or jointly by 1 or more employers and 1 or more 
     employee organizations,
       ``(ii) a multiple employer welfare arrangement, or
       ``(iii) a voluntary employees' beneficiary association 
     described in section 501(c)(9),

     the association, committee, joint board of trustees, or other 
     similar group of representatives of the parties who establish 
     or maintain the plan, or
       ``(D) the cooperative or association described in 
     subsection (c)(2)(F) in the case of a plan established or 
     maintained by such a cooperative or association.
       ``(c) Applicable Self-Insured Health Plan.--For purposes of 
     this section, the term `applicable self-insured health plan' 
     means any plan for providing accident or health coverage if--
       ``(1) any portion of such coverage is provided other than 
     through an insurance policy, and
       ``(2) such plan is established or maintained--
       ``(A) by one or more employers for the benefit of their 
     employees or former employees,
       ``(B) by one or more employee organizations for the benefit 
     of their members or former members,
       ``(C) jointly by 1 or more employers and 1 or more employee 
     organizations for the benefit of employees or former 
     employees,
       ``(D) by a voluntary employees' beneficiary association 
     described in section 501(c)(9),
       ``(E) by any organization described in section 501(c)(6), 
     or
       ``(F) in the case of a plan not described in the preceding 
     subparagraphs, by a multiple employer welfare arrangement (as 
     defined in section 3(40) of Employee Retirement Income 
     Security Act of 1974), a rural electric cooperative (as 
     defined in section 3(40)(B)(iv) of such Act), or a rural 
     telephone cooperative association (as defined in section 
     3(40)(B)(v) of such Act).

     ``SEC. 4377. DEFINITIONS AND SPECIAL RULES.

       ``(a) Definitions.--For purposes of this subchapter--
       ``(1) Accident and health coverage.--The term `accident and 
     health coverage' means any coverage which, if provided by an 
     insurance policy, would cause such policy to be a specified 
     health insurance policy (as defined in section 4375(c)).
       ``(2) Insurance policy.--The term `insurance policy' means 
     any policy or other instrument whereby a contract of 
     insurance is issued, renewed, or extended.
       ``(3) United states.--The term `United States' includes any 
     possession of the United States.
       ``(b) Treatment of Governmental Entities.--
       ``(1) In general.--For purposes of this subchapter--
       ``(A) the term `person' includes any governmental entity, 
     and
       ``(B) notwithstanding any other law or rule of law, 
     governmental entities shall not be exempt from the fees 
     imposed by this subchapter except as provided in paragraph 
     (2).
       ``(2) Treatment of exempt governmental programs.--In the 
     case of an exempt governmental program, no fee shall be 
     imposed under section 4375 or section 4376 on any covered 
     life under such program.
       ``(3) Exempt governmental program defined.--For purposes of 
     this subchapter, the term `exempt governmental program' 
     means--
       ``(A) any insurance program established under title XVIII 
     of the Social Security Act,
       ``(B) the medical assistance program established by title 
     XIX or XXI of the Social Security Act,
       ``(C) any program established by Federal law for providing 
     medical care (other than through insurance policies) to 
     individuals (or the spouses and dependents thereof) by reason 
     of such individuals being--
       ``(i) members of the Armed Forces of the United States, or
       ``(ii) veterans, and
       ``(D) any program established by Federal law for providing 
     medical care (other than through insurance policies) to 
     members of Indian tribes (as defined in section 4(d) of the 
     Indian Health Care Improvement Act).
       ``(c) Treatment as Tax.--For purposes of subtitle F, the 
     fees imposed by this subchapter shall be treated as if they 
     were taxes.
       ``(d) No Cover Over to Possessions.--Notwithstanding any 
     other provision of law, no amount collected under this 
     subchapter shall be covered over to any possession of the 
     United States.''.
       (2) Clerical amendments.--
       (A) Chapter 34 of such Code is amended by striking the 
     chapter heading and inserting the following:

           ``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES

          ``subchapter a. policies issued by foreign insurers

         ``subchapter b. insured and self-insured health plans

         ``Subchapter A--Policies Issued By Foreign Insurers''.

       (B) The table of chapters for subtitle D of such Code is 
     amended by striking the item relating to chapter 34 and 
     inserting the following new item:

          ``Chapter 34--Taxes on Certain Insurance Policies''.

       (3) Effective date.--The amendments made by this subsection 
     shall apply with respect to policies and plans for portions 
     of policy or plan years beginning on or after October 1, 
     2012.

                   TITLE IX--MISCELLANEOUS PROVISIONS

     SEC. 1901. REPEAL OF TRIGGER PROVISION.

       Subtitle A of title VIII of the Medicare Prescription Drug, 
     Improvement, and Modernization Act of 2003 (Public Law 108-
     173) is repealed and the provisions of law amended by such 
     subtitle are restored as if such subtitle had never been 
     enacted.

     SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) 
                   PROGRAM.

       Section 1860C-1 of the Social Security Act (42 U.S.C. 
     1395w-29), as added by section 241(a) of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (Public Law 108-173), is repealed.

     SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION.

       (a) In General.--Subsection (d)(3) of section 5007 of the 
     Deficit Reduction Act of 2005 (Public Law 109-171) is amended 
     by inserting ``(or September 30, 2011, in the case of a 
     demonstration project in operation as of October 1, 2008)'' 
     after ``December 31, 2009''.
       (b) Funding.--
       (1) In general.--Subsection (f)(1) of such section is 
     amended by inserting ``and for fiscal year 2010, 
     $1,600,000,'' after ``$6,000,000,''.
       (2) Availability.--Subsection (f)(2) of such section is 
     amended by striking ``2010'' and inserting ``2014 or until 
     expended''.
       (c) Reports.--
       (1) Quality improvement and savings.--Subsection (e)(3) of 
     such section is amended by striking ``December 1, 2008'' and 
     inserting ``March 31, 2011''.
       (2) Final report.--Subsection (e)(4) of such section is 
     amended by striking ``May 1, 2010'' and inserting ``March 31, 
     2013''.

     SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITATION 
                   PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN AND 
                   FAMILIES EXPECTING CHILDREN.

       Part B of title IV of the Social Security Act (42 U.S.C. 
     621-629i) is amended by adding at the end the following:

       ``Subpart 3--Support for Quality Home Visitation Programs

     ``SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG 
                   CHILDREN AND FAMILIES EXPECTING CHILDREN.

       ``(a) Purpose.--The purpose of this section is to improve 
     the well-being, health, and development of children by 
     enabling the establishment and expansion of high quality 
     programs providing voluntary home visitation for families 
     with young children and families expecting children.
       ``(b) Grant Application.--A State that desires to receive a 
     grant under this section shall submit to the Secretary for 
     approval, at such time and in such manner as the Secretary 
     may require, an application for the grant that includes the 
     following:
       ``(1) Description of home visitation programs.--A 
     description of the high quality programs of home visitation 
     for families with young children and families expecting 
     children that will be supported by a grant made to the State 
     under this section, the outcomes the programs are intended to 
     achieve, and the evidence supporting the effectiveness of the 
     programs.
       ``(2) Results of needs assessment.--The results of a 
     statewide needs assessment that describes--
       ``(A) the number, quality, and capacity of home visitation 
     programs for families with young children and families 
     expecting children in the State;
       ``(B) the number and types of families who are receiving 
     services under the programs;
       ``(C) the sources and amount of funding provided to the 
     programs;
       ``(D) the gaps in home visitation in the State, including 
     identification of communities that are in high need of the 
     services; and
       ``(E) training and technical assistance activities designed 
     to achieve or support the goals of the programs.
       ``(3) Assurances.--Assurances from the State that--
       ``(A) in supporting home visitation programs using funds 
     provided under this section, the State shall identify and 
     prioritize serving communities that are in high need of such 
     services, especially communities with a high proportion of 
     low-income families or a high incidence of child 
     maltreatment;
       ``(B) the State will reserve 5 percent of the grant funds 
     for training and technical assistance to the home visitation 
     programs using such funds;

[[Page 27342]]

       ``(C) in supporting home visitation programs using funds 
     provided under this section, the State will promote 
     coordination and collaboration with other home visitation 
     programs (including programs funded under title XIX) and with 
     other child and family services, health services, income 
     supports, and other related assistance;
       ``(D) home visitation programs supported using such funds 
     will, when appropriate, provide referrals to other programs 
     serving children and families; and
       ``(E) the State will comply with subsection (i), and 
     cooperate with any evaluation conducted under subsection (j).
       ``(4) Other information.--Such other information as the 
     Secretary may require.
       ``(c) Allotments.--
       ``(1) Indian tribes.--From the amount reserved under 
     subsection (l)(2) for a fiscal year, the Secretary shall 
     allot to each Indian tribe that meets the requirement of 
     subsection (d), if applicable, for the fiscal year the amount 
     that bears the same ratio to the amount so reserved as the 
     number of children in the Indian tribe whose families have 
     income that does not exceed 200 percent of the poverty line 
     bears to the total number of children in such Indian tribes 
     whose families have income that does not exceed 200 percent 
     of the poverty line.
       ``(2) States and territories.--From the amount appropriated 
     under subsection (m) for a fiscal year that remains after 
     making the reservations required by subsection (l), the 
     Secretary shall allot to each State that is not an Indian 
     tribe and that meets the requirement of subsection (d), if 
     applicable, for the fiscal year the amount that bears the 
     same ratio to the remainder of the amount so appropriated as 
     the number of children in the State whose families have 
     income that does not exceed 200 percent of the poverty line 
     bears to the total number of children in such States whose 
     families have income that does not exceed 200 percent of the 
     poverty line.
       ``(3) Reallotments.--The amount of any allotment to a State 
     under a paragraph of this subsection for any fiscal year that 
     the State certifies to the Secretary will not be expended by 
     the State pursuant to this section shall be available for 
     reallotment using the allotment methodology specified in that 
     paragraph. Any amount so reallotted to a State is deemed part 
     of the allotment of the State under this subsection.
       ``(d) Maintenance of Effort.--Beginning with fiscal year 
     2011, a State meets the requirement of this subsection for a 
     fiscal year if the Secretary finds that the aggregate 
     expenditures by the State from State and local sources for 
     programs of home visitation for families with young children 
     and families expecting children for the then preceding fiscal 
     year was not less than 100 percent of such aggregate 
     expenditures for the then 2nd preceding fiscal year.
       ``(e) Payment of Grant.--
       ``(1) In general.--The Secretary shall make a grant to each 
     State that meets the requirements of subsections (b) and (d), 
     if applicable, for a fiscal year for which funds are 
     appropriated under subsection (m), in an amount equal to the 
     reimbursable percentage of the eligible expenditures of the 
     State for the fiscal year, but not more than the amount 
     allotted to the State under subsection (c) for the fiscal 
     year.
       ``(2) Reimbursable percentage defined.--In paragraph (1), 
     the term `reimbursable percentage' means, with respect to a 
     fiscal year--
       ``(A) 85 percent, in the case of fiscal year 2010;
       ``(B) 80 percent, in the case of fiscal year 2011; or
       ``(C) 75 percent, in the case of fiscal year 2012 and any 
     succeeding fiscal year.
       ``(f) Eligible Expenditures.--
       ``(1) In general.--In this section, the term `eligible 
     expenditures'--
       ``(A) means expenditures to provide voluntary home 
     visitation for as many families with young children (under 
     the age of school entry) and families expecting children as 
     practicable, through the implementation or expansion of high 
     quality home visitation programs that--
       ``(i) adhere to clear evidence-based models of home 
     visitation that have demonstrated positive effects on 
     important program-determined child and parenting outcomes, 
     such as reducing abuse and neglect and improving child health 
     and development;
       ``(ii) employ well-trained and competent staff, maintain 
     high quality supervision, provide for ongoing training and 
     professional development, and show strong organizational 
     capacity to implement such a program;
       ``(iii) establish appropriate linkages and referrals to 
     other community resources and supports;
       ``(iv) monitor fidelity of program implementation to ensure 
     that services are delivered according to the specified model; 
     and
       ``(v) provide parents with--

       ``(I) knowledge of age-appropriate child development in 
     cognitive, language, social, emotional, and motor domains 
     (including knowledge of second language acquisition, in the 
     case of English language learners);
       ``(II) knowledge of realistic expectations of age-
     appropriate child behaviors;
       ``(III) knowledge of health and wellness issues for 
     children and parents;
       ``(IV) modeling, consulting, and coaching on parenting 
     practices;
       ``(V) skills to interact with their child to enhance age-
     appropriate development;
       ``(VI) skills to recognize and seek help for issues related 
     to health, developmental delays, and social, emotional, and 
     behavioral skills; and
       ``(VII) activities designed to help parents become full 
     partners in the education of their children;

       ``(B) includes expenditures for training, technical 
     assistance, and evaluations related to the programs; and
       ``(C) does not include any expenditure with respect to 
     which a State has submitted a claim for payment under any 
     other provision of Federal law.
       ``(2) Priority funding for programs with strongest 
     evidence.--
       ``(A) In general.--The expenditures, described in paragraph 
     (1), of a State for a fiscal year that are attributable to 
     the cost of programs that do not adhere to a model of home 
     visitation with the strongest evidence of effectiveness shall 
     not be considered eligible expenditures for the fiscal year 
     to the extent that the total of the expenditures exceeds the 
     applicable percentage for the fiscal year of the allotment of 
     the State under subsection (c) for the fiscal year.
       ``(B) Applicable percentage defined.--In subparagraph (A), 
     the term `applicable percentage' means, with respect to a 
     fiscal year--
       ``(i) 60 percent for fiscal year 2010;
       ``(ii) 55 percent for fiscal year 2011;
       ``(iii) 50 percent for fiscal year 2012;
       ``(iv) 45 percent for fiscal year 2013; or
       ``(v) 40 percent for fiscal year 2014.
       ``(g) No Use of Other Federal Funds for State Match.--A 
     State to which a grant is made under this section may not 
     expend any Federal funds to meet the State share of the cost 
     of an eligible expenditure for which the State receives a 
     payment under this section.
       ``(h) Waiver Authority.--
       ``(1) In general.--The Secretary may waive or modify the 
     application of any provision of this section, other than 
     subsection (b) or (f), to an Indian tribe if the failure to 
     do so would impose an undue burden on the Indian tribe.
       ``(2) Special rule.--An Indian tribe is deemed to meet the 
     requirement of subsection (d) for purposes of subsections (c) 
     and (e) if--
       ``(A) the Secretary waives the requirement; or
       ``(B) the Secretary modifies the requirement, and the 
     Indian tribe meets the modified requirement.
       ``(i) State Reports.--Each State to which a grant is made 
     under this section shall submit to the Secretary an annual 
     report on the progress made by the State in addressing the 
     purposes of this section. Each such report shall include a 
     description of--
       ``(1) the services delivered by the programs that received 
     funds from the grant;
       ``(2) the characteristics of each such program, including 
     information on the service model used by the program and the 
     performance of the program;
       ``(3) the characteristics of the providers of services 
     through the program, including staff qualifications, work 
     experience, and demographic characteristics;
       ``(4) the characteristics of the recipients of services 
     provided through the program, including the number of the 
     recipients, the demographic characteristics of the 
     recipients, and family retention;
       ``(5) the annual cost of implementing the program, 
     including the cost per family served under the program;
       ``(6) the outcomes experienced by recipients of services 
     through the program;
       ``(7) the training and technical assistance provided to aid 
     implementation of the program, and how the training and 
     technical assistance contributed to the outcomes achieved 
     through the program;
       ``(8) the indicators and methods used to monitor whether 
     the program is being implemented as designed; and
       ``(9) other information as determined necessary by the 
     Secretary.
       ``(j) Evaluation.--
       ``(1) In general.--The Secretary shall, by grant or 
     contract, provide for the conduct of an independent 
     evaluation of the effectiveness of home visitation programs 
     receiving funds provided under this section, which shall 
     examine the following:
       ``(A) The effect of home visitation programs on child and 
     parent outcomes, including child maltreatment, child health 
     and development, school readiness, and links to community 
     services.
       ``(B) The effectiveness of home visitation programs on 
     different populations, including the extent to which the 
     ability of programs to improve outcomes varies across 
     programs and populations.
       ``(2) Reports to the congress.--
       ``(A) Interim report.--Within 3 years after the date of the 
     enactment of this section, the Secretary shall submit to the 
     Congress an interim report on the evaluation conducted 
     pursuant to paragraph (1).
       ``(B) Final report.--Within 5 years after the date of the 
     enactment of this section, the Secretary shall submit to the 
     Congress a final report on the evaluation conducted pursuant 
     to paragraph (1).
       ``(k) Annual Reports to the Congress.--The Secretary shall 
     submit annually to the

[[Page 27343]]

     Congress a report on the activities carried out using funds 
     made available under this section, which shall include a 
     description of the following:
       ``(1) The high need communities targeted by States for 
     programs carried out under this section.
       ``(2) The service delivery models used in the programs 
     receiving funds provided under this section.
       ``(3) The characteristics of the programs, including--
       ``(A) the qualifications and demographic characteristics of 
     program staff; and
       ``(B) recipient characteristics including the number of 
     families served, the demographic characteristics of the 
     families served, and family retention and duration of 
     services.
       ``(4) The outcomes reported by the programs.
       ``(5) The research-based instruction, materials, and 
     activities being used in the activities funded under the 
     grant.
       ``(6) The training and technical activities, including on-
     going professional development, provided to the programs.
       ``(7) The annual costs of implementing the programs, 
     including the cost per family served under the programs.
       ``(8) The indicators and methods used by States to monitor 
     whether the programs are being been implemented as designed.
       ``(l) Reservations of Funds.--From the amounts appropriated 
     for a fiscal year under subsection (m), the Secretary shall 
     reserve--
       ``(1) an amount equal to 5 percent of the amounts to pay 
     the cost of the evaluation provided for in subsection (j), 
     and the provision to States of training and technical 
     assistance, including the dissemination of best practices in 
     early childhood home visitation; and
       ``(2) after making the reservation required by paragraph 
     (1), an amount equal to 3 percent of the amount so 
     appropriated, to pay for grants to Indian tribes under this 
     section.
       ``(m) Appropriations.--Out of any money in the Treasury of 
     the United States not otherwise appropriated, there is 
     appropriated to the Secretary to carry out this section--
       ``(1) $50,000,000 for fiscal year 2010;
       ``(2) $100,000,000 for fiscal year 2011;
       ``(3) $150,000,000 for fiscal year 2012;
       ``(4) $200,000,000 for fiscal year 2013; and
       ``(5) $250,000,000 for fiscal year 2014.
       ``(n) Indian Tribes Treated as States.--In this section, 
     paragraphs (4), (5), and (6) of section 431(a) shall 
     apply.''.

     SEC. 1905. IMPROVED COORDINATION AND PROTECTION FOR DUAL 
                   ELIGIBLES.

       Title XI of the Social Security Act is amended by inserting 
     after section 1150 the following new section:


       ``improved coordination and protection for dual eligibles

       ``Sec. 1150A.  (a) In General.--The Secretary shall 
     provide, through an identifiable office or program within the 
     Centers for Medicare & Medicaid Services, for a focused 
     effort to provide for improved coordination between Medicare 
     and Medicaid and protection in the case of dual eligibles (as 
     defined in subsection (g)). The office or program shall--
       ``(1) review Medicare and Medicaid policies related to 
     enrollment, benefits, service delivery, payment, and 
     grievance and appeals processes under parts A and B of title 
     XVIII, under the Medicare Advantage program under part C of 
     such title, and under title XIX;
       ``(2) identify areas of such policies where better 
     coordination and protection could improve care and costs; and
       ``(3) issue guidance to States regarding improving such 
     coordination and protection.
       ``(b) Elements.--The improved coordination and protection 
     under this section shall include efforts--
       ``(1) to simplify access of dual eligibles to benefits and 
     services under Medicare and Medicaid;
       ``(2) to improve care continuity for dual eligibles and 
     ensure safe and effective care transitions;
       ``(3) to harmonize regulatory conflicts between Medicare 
     and Medicaid rules with regard to dual eligibles; and
       ``(4) to improve total cost and quality performance under 
     Medicare and Medicaid for dual eligibles.
       ``(c) Responsibilities.--In carrying out this section, the 
     Secretary shall provide for the following:
       ``(1) An examination of Medicare and Medicaid payment 
     systems to develop strategies to foster more integrated and 
     higher quality care.
       ``(2) Development of methods to facilitate access to post-
     acute and community-based services and to identify actions 
     that could lead to better coordination of community-based 
     care.
       ``(3) A study of enrollment of dual eligibles in the 
     Medicare Savings Program (as defined in section 1144(c)(7)), 
     under Medicaid, and in the low-income subsidy program under 
     section 1860D-14 to identify methods to more efficiently and 
     effectively reach and enroll dual eligibles.
       ``(4) An assessment of communication strategies for dual 
     eligibles to determine whether additional informational 
     materials or outreach is needed, including an assessment of 
     the Medicare website, 1-800-MEDICARE, and the Medicare 
     handbook.
       ``(5) Research and evaluation of areas where service 
     utilization, quality, and access to cost sharing protection 
     could be improved and an assessment of factors related to 
     enrollee satisfaction with services and care delivery.
       ``(6) Collection (and making available to the public) of 
     data and a database that describe the eligibility, benefit 
     and cost-sharing assistance available to dual eligibles by 
     State.
       ``(7) Support for coordination of State and Federal 
     contracting and oversight for dual coordination programs 
     supportive of the goals described in subsection (b).
       ``(8) Support for State Medicaid agencies through the 
     provision of technical assistance for Medicare and Medicaid 
     coordination initiatives designed to improve acute and long-
     term care for dual eligibles.
       ``(9) Monitoring total combined Medicare and Medicaid 
     program costs in serving dual eligibles and making 
     recommendations for optimizing total quality and cost 
     performance across both programs.
       ``(10) Coordination of activities relating to Medicare 
     Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
       ``(d) Reporting.--The Office or program shall work with 
     relevant State agencies and any appropriate quality 
     measurement entities to improve and coordinate reporting 
     requirements for Medicare and Medicaid. In addition, the 
     Office or program shall seek to minimize duplication in 
     reporting requirements, where appropriate, and to identify 
     opportunities to combine assessment requirements, where 
     appropriate. The Office or program shall seek to identify 
     quality metrics and assessment requirements that facilitate 
     comparisons of the quality of care received by beneficiaries 
     enrolled in or entitled to benefits under fee-for-service 
     Medicare, the Medicare Advantage program, fee-for-service 
     Medicaid, and Medicaid managed care, and combinations thereof 
     (including integrated Medicare-Medicaid programs for dual 
     eligibles).
       ``(e) Endorsement.--The Secretary shall seek endorsement by 
     the entity with a contract under section 1890(a) of quality 
     measures and benchmarks developed under this section.
       ``(f) Consultation With Stakeholders.--The Office or 
     program shall consult with relevant stakeholders, including 
     dual eligible beneficiaries representatives for dual eligible 
     beneficiaries, health plans, providers, and relevant State 
     agencies, in the development of policies related to 
     integrated Medicare-Medicaid programs for dual eligibles.
       ``(g) Periodic Reports.--Not later than 1 year after the 
     date of the enactment of this section and every 3 years 
     thereafter the Secretary shall submit to Congress a report on 
     progress in activities conducted under this section.
       ``(h) Definitions.--In this section:
       ``(1) Dual eligible.--The term `dual eligible' means an 
     individual who is dually eligible for benefits under title 
     XVIII, and medical assistance under title XIX, including such 
     individuals who are eligible for benefits under the Medicare 
     Savings Program (as defined in section 1144(c)(7)).
       ``(2) Medicare; medicaid.--The terms `Medicare' and 
     `Medicaid' mean the programs under titles XVIII and XIX, 
     respectively.''.

     SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE DISEASES AND 
                   CONDITIONS.

       (a) Initial Assessment.--
       (1) In general.--The Secretary of Health and Human Services 
     shall conduct an assessment of the diseases and conditions 
     that are the most cost-intensive for the Medicare program 
     and, to the extent possible, assess the diseases and 
     conditions that could become cost-intensive for Medicare in 
     the future. In conducting the assessment, the Secretary shall 
     include the input of relevant research agencies, including 
     the National Institutes of Health, the Agency for Healthcare 
     Research and Quality, the Food and Drug Administration, and 
     the Centers for Medicare & Medicaid Services.
       (2) Report.--Not later than January 1, 2011, the Secretary 
     shall transmit a report to the Committees on Energy and 
     Commerce, Ways and Means, and Appropriations of the House of 
     Representatives and the Committees on Health, Education, 
     Labor and Pensions, Finance, and Appropriations of the Senate 
     on the assessment conducted under paragraph (1). Such report 
     shall--
       (A) include the assessment of current and future trends of 
     cost-intensive diseases and conditions described in such 
     paragraph;
       (B) address whether current research priorities are 
     appropriately addressing current and future cost-intensive 
     conditions so identified; and
       (C) include recommendations concerning research in the 
     Department of Health and Human Services that should be funded 
     to improve the prevention, treatment, or cure of such cost-
     intensive diseases and conditions.
       (b) Updates of Assessment.--Not later than January 1, 2013, 
     and biennially thereafter, the Secretary shall--
       (1) review and update the assessment and recommendations 
     described in subsection (a)(1); and

[[Page 27344]]

       (2) submit a report described in subsection (a)(2) to the 
     Committees specified in subsection (a)(2) on such updated 
     assessment and recommendations.

     SEC. 1907. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID 
                   INNOVATION WITHIN CMS.

       (a) In General.--Title XI of the Social Security Act is 
     amended by inserting after section 1115 the following new 
     section:


             ``center for medicare and medicaid innovation

       ``Sec. 1115A.  (a) Center for Medicare and Medicaid 
     Innovation Established.--
       ``(1) In general.--There is created within the Centers for 
     Medicare & Medicaid Services a Center for Medicare and 
     Medicaid Innovation (in this section referred to as the 
     `CMI') to carry out the duties described in this section. The 
     purpose of the CMI is to test innovative payment and service 
     delivery models to improve the coordination, quality, and 
     efficiency of health care services provided to applicable 
     individuals defined in paragraph (4)(A).
       ``(2) Deadline.--The Secretary shall ensure that the CMI is 
     carrying out the duties described in this section by not 
     later than January 1, 2011.
       ``(3) Consultation.--In carrying out the duties under this 
     section, the CMI shall consult representatives of relevant 
     Federal agencies, clinical and analytical experts with 
     expertise in medicine and health care management, and States. 
     The CMI shall use open door forums or other mechanisms to 
     seek input from interested parties.
       ``(4) Definitions.--In this section:
       ``(A) Applicable individual.--The term `applicable 
     individual' means--
       ``(i) an individual who is enrolled under part B and 
     entitled to benefits under part A of title XVIII;
       ``(ii) an individual who is eligible for medical assistance 
     under title XIX; or
       ``(iii) an individual who meets the criteria of both 
     clauses (i) and (ii).
       ``(B) Applicable title.--The term `applicable title' means 
     title XVIII, title XIX, or both.
       ``(b) Testing of Models (Phase I).--
       ``(1) In general.--The CMI shall test payment and service 
     delivery models in accordance with selection criteria under 
     paragraph (2) to determine the effect of applying such models 
     under the applicable title (as defined in subsection 
     (a)(4)(B)) on program expenditures under such titles and the 
     quality of care received by individuals receiving benefits 
     under such title.
       ``(2) Selection of models to be tested.--
       ``(A) In general.--The Secretary shall give preference to 
     testing models for which, as determined by the Administrator 
     of the Centers for Medicare & Medicaid Services and using 
     such input from outside the Centers as the Administrator 
     determines appropriate, there is evidence that the model 
     addresses a defined population for which there are deficits 
     in care leading to poor clinical outcomes or potentially 
     avoidable expenditures. The Administrator shall focus on 
     models expected to reduce program costs under the applicable 
     title while preserving or enhancing the quality of care 
     received by individuals receiving benefits under such title.
       ``(B) Application to other demonstrations.--The Secretary 
     shall operate the demonstration programs under sections 1222 
     and 1236 of the Affordable Health Care for America Act 
     through the CMI in accordance with the rules applicable under 
     this section, including those relating to evaluations, 
     terminations, and expansions.
       ``(3) Budget neutrality.--
       ``(A) Initial period.--The Secretary shall not require, as 
     a condition for testing a model under paragraph (1), that the 
     design of such model ensure that such model is budget neutral 
     initially with respect to expenditures under the applicable 
     title.
       ``(B) Termination.--The Secretary shall terminate or modify 
     the design and implementation of a model unless the Secretary 
     determines (and the Chief Actuary of the Centers for Medicare 
     & Medicaid Services, with respect to spending under the 
     applicable title, certifies), after testing has begun, that 
     the model is expected to--
       ``(i) improve the quality of care (as determined by the 
     Administrator of the Centers for Medicare & Medicaid 
     Services) without increasing spending under such title;
       ``(ii) reduce spending under such titles without reducing 
     the quality of care; or
       ``(iii) do both.

     Such termination may occur at any time after such testing has 
     begun and before completion of the testing.
       ``(4) Evaluation.--
       ``(A) In general.--The Secretary shall conduct an 
     evaluation of each model tested under this subsection. Such 
     evaluation shall include an analysis of--
       ``(i) the quality of care furnished under the model, 
     including through the use of patient-level outcomes measures; 
     and
       ``(ii) the changes in spending under the applicable titles 
     by reason of the model.

     The Secretary shall make the results of each evaluation under 
     this paragraph available to the public in a timely fashion.
       ``(B) Measure selection.--To the extent feasible, the 
     Secretary shall select measures under this paragraph that 
     reflect national priorities for quality improvement and 
     patient-centered care consistent with the measures developed 
     under section 1192(c)(1).
       ``(5) Testing period.--In no case shall a model be tested 
     under this subsection for more than a 7-year period.
       ``(c) Expansion of Models (Phase II).--The Secretary may 
     expand the duration and the scope of a model that is being 
     tested under subsection (b) (including implementation on a 
     nationwide basis), to the extent determined appropriate by 
     the Secretary, if--
       ``(1) the Secretary determines that such expansion is 
     expected--
       ``(A) to improve the quality of patient care without 
     increasing spending under the applicable titles;
       ``(B) to reduce spending under applicable titles without 
     reducing the quality of care; or
       ``(C) to do both;
       ``(2) the Chief Actuary of the Centers for Medicare & 
     Medicaid Services certifies that such expansion would reduce 
     (or not result in any increase in) net program spending under 
     applicable titles; and
       ``(3) the Secretary determines that such expansion would 
     not deny or limit the coverage or provision of benefits under 
     the applicable title for applicable individuals.
       ``(d) Implementation.--
       ``(1) Waiver authority.--The Secretary may waive such 
     requirements of titles XI and XVIII and of sections 1902 and 
     1903(m) as may be necessary solely for purposes of carrying 
     out this section with respect to testing models described in 
     subsection (b).
       ``(2) Limitations on review.--There shall be no 
     administrative or judicial review under section 1869, section 
     1878, or otherwise of--
       ``(A) the selection of models for testing or expansion 
     under this section;
       ``(B) the elements, parameters, scope, and duration of such 
     models for testing or dissemination;
       ``(C) the termination or modification of the design and 
     implementation of a model under subsection (b)(3)(B); and
       ``(D) determinations about expansion of the duration and 
     scope of a model under subsection (c) including the 
     determination that a model is not expected to meet criteria 
     described in paragraphs (1) or (2) of such subsection.
       ``(3) Administration.--Chapter 35 of title 44, United 
     States Code shall not apply to the testing and evaluation of 
     models or expansion of such models under this section.
       ``(4) Funding for testing items and services and 
     administrative costs.--
       ``(A) Additional benefits.--There shall be available until 
     expended, equally divided from the Federal Supplementary 
     Hospital Insurance Trust Fund and Federal Supplementary 
     Medical Insurance Trust Fund for payments for additional 
     benefits for items and services under models tested under 
     subsection (b) not otherwise covered under this title and 
     applicable to benefits under this title, and for researching, 
     designing, implementing, and evaluating such models, 
     $350,000,000 for fiscal year 2010, $440,000,000 for fiscal 
     year 2011, $550,000,000 for fiscal year 2012, and, for a 
     subsequent fiscal year, the amount determined under this 
     subparagraph for the preceding fiscal year increased by the 
     annual percentage rate of increase in total expenditures 
     under this title for the subsequent fiscal year as estimated 
     in the latest available Annual Report of the Board of 
     Trustees as described in section 1841(b)(2).
       ``(B) Medicaid.--For administrative costs of the Centers 
     for Medicare & Medicaid Services for administering this 
     section with respect to title XIX, from any amounts in the 
     Treasury not otherwise appropriated there are appropriated to 
     the Secretary for the Centers for Medicare & Medicaid 
     Services Program Management Account $25,000,000 for each 
     fiscal year beginning with fiscal year 2010. Amounts 
     appropriated under this subparagraph for a fiscal year shall 
     be available until expended.
       ``(e) Report to Congress.--Beginning in 2012, and not less 
     than once every other year thereafter, the Secretary shall 
     submit to Congress a report on activities under this section. 
     Each such report shall describe the payment models tested 
     under subsection (b), including the number of individuals 
     described in subsection (a)(4)(A)(i) and of individuals 
     described in subsection (a)(4)(A)(ii) participating in such 
     models and payments made under applicable titles for services 
     on behalf of such individuals, any models chosen for 
     expansion under subsection (c), and the results from 
     evaluations under subsection (b)(4). In addition, each such 
     report shall provide such recommendations as the Secretary 
     believes are appropriate for legislative action to facilitate 
     the development and expansion of successful payment 
     models.''.
       (b) Medicaid Conforming Amendment.--Section 1902(a) of the 
     Social Security Act (42 U.S.C. 1396a(a)), as amended by 
     sections 1631(b), 1703(a), 1729, 1753, 1757(a), and 1759(a), 
     is amended--
       (1) in paragraph (78), by striking ``and'' at the end;
       (2) in paragraph (79), by striking the period at the end 
     and inserting ``; and''; and
       (3) by inserting after paragraph (79) the following new 
     paragraph:
       ``(80) provide for implementation of the payment models 
     specified by the Secretary

[[Page 27345]]

     under section 1115A(c) for implementation on a nationwide 
     basis unless the State demonstrates to the satisfaction of 
     the Secretary that implementation would not be 
     administratively feasible or appropriate to the health care 
     delivery system of the State.''.

     SEC. 1908. APPLICATION OF EMERGENCY SERVICES LAWS.

       Nothing in this Act shall be construed to relieve any 
     health care provider from providing emergency services as 
     required by State or Federal law, including section 1867 of 
     the Social Security Act (popularly known as ``EMTALA'').

     SEC. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECURITY INCOME 
                   PROGRAM OF COMPENSATION FOR PARTICIPATION IN 
                   CLINICAL TRIALS FOR RARE DISEASES OR 
                   CONDITIONS.

       (a) Income Disregard.--Section 1612(b) of the Social 
     Security Act (42 U.S.C. 1382a(b)) is amended--
       (1) by striking ``and'' at the end of paragraph (24);
       (2) by striking the period at the end of paragraph (25) and 
     inserting ``; and''; and
       (3) by adding at the end the following:
       ``(26) The first $2,000 per year received by such 
     individual (or such spouse) for participation in a clinical 
     trial to test a treatment for a rare disease or condition 
     (within the meaning of section 5(b)(2) of the Orphan Drug Act 
     (Public Law 97-414)), that--
       ``(A) has been reviewed and approved by an institutional 
     review board that--
       ``(i) is established to protect the rights and welfare of 
     human subjects participating in research; and
       ``(ii) meet the standards for such bodies set forth in part 
     46 of title 45, Code of Federal Regulations; and
       ``(B) meets the standards for protection of human subjects 
     for clinical research (as set forth in such part).''.
       (b) Resource Disregard.--Section 1613(a) of such Act (42 
     U.S.C. 1382b(a)) is amended--
       (1) by striking ``and'' at the end of paragraph (15);
       (2) by striking the period at the end of paragraph (16) and 
     inserting ``; and''; and
       (3) by inserting after paragraph (16) the following:
       ``(17) the first $2,000 per year received by such 
     individual (or such spouse) for participation in a clinical 
     trial, as described in section 1612(b)(26).''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to benefits payable for calendar months beginning 
     after the earlier of--
       (1) the date the Commissioner of Social Security 
     promulgates regulations to carry out the amendments; or
       (2) the 180-day period that begins with the date of the 
     enactment of this Act.

          DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

     SEC. 2001. TABLE OF CONTENTS; REFERENCES.

       (a) Table of Contents.--The table of contents of this 
     division is as follows:

Sec. 2001. Table of contents; references.
Sec. 2002. Public Health Investment Fund.
Sec. 2003. Deficit neutrality.

                   TITLE I--COMMUNITY HEALTH CENTERS

Sec. 2101. Increased funding.

                          TITLE II--WORKFORCE

                   Subtitle A--Primary Care Workforce

                 Part 1--National Health Service Corps

Sec. 2201. National Health Service Corps.
Sec. 2202. Authorizations of appropriations.

            Part 2--Promotion of Primary Care and Dentistry

Sec. 2211. Frontline health providers.

             ``subpart xi--health professional needs areas

``Sec. 340H. In general.
``Sec. 340I. Loan repayments.
``Sec. 340J. Report.
``Sec. 340K. Allocation.
Sec. 2212. Primary care student loan funds.
Sec. 2213. Training in family medicine, general internal medicine, 
              general pediatrics, geriatrics, and physician assistants.
Sec. 2214. Training of medical residents in community-based settings.
Sec. 2215. Training for general, pediatric, and public health dentists 
              and dental hygienists.
Sec. 2216. Authorization of appropriations.
Sec. 2217. Study on effectiveness of scholarships and loan repayments.

                     Subtitle B--Nursing Workforce

Sec. 2221. Amendments to Public Health Service Act.

                  Subtitle C--Public Health Workforce

Sec. 2231. Public Health Workforce Corps.

                 ``subpart xii--public health workforce

``Sec. 340L. Public Health Workforce Corps.
``Sec. 340M. Public Health Workforce Scholarship Program.
``Sec. 340N. Public Health Workforce Loan Repayment Program.
Sec. 2232. Enhancing the public health workforce.
Sec. 2233. Public health training centers.
Sec. 2234. Preventive medicine and public health training grant 
              program.
Sec. 2235. Authorization of appropriations.

     Subtitle D--Adapting Workforce to Evolving Health System Needs

           Part 1--Health Professions Training for Diversity

Sec. 2241. Scholarships for disadvantaged students, loan repayments and 
              fellowships regarding faculty positions, and educational 
              assistance in the health professions regarding 
              individuals from disadvantaged backgrounds.
Sec. 2242. Nursing workforce diversity grants.
Sec. 2243. Coordination of diversity and cultural competency programs.

              Part 2--Interdisciplinary Training Programs

Sec. 2251. Cultural and linguistic competency training for health 
              professionals.
Sec. 2252. Innovations in interdisciplinary care training.

     Part 3--Advisory Committee on Health Workforce Evaluation and 
                               Assessment

Sec. 2261. Health workforce evaluation and assessment.

                  Part 4--Health Workforce Assessment

Sec. 2271. Health workforce assessment.

                Part 5--Authorization of Appropriations

Sec. 2281. Authorization of appropriations.

                   TITLE III--PREVENTION AND WELLNESS

Sec. 2301. Prevention and wellness.

                 ``TITLE XXXI--PREVENTION AND WELLNESS

              ``Subtitle A--Prevention and Wellness Trust

``Sec. 3111. Prevention and Wellness Trust.

        ``Subtitle B--National Prevention and Wellness Strategy

``Sec. 3121. National Prevention and Wellness Strategy.

                  ``Subtitle C--Prevention Task Forces

``Sec. 3131. Task Force on Clinical Preventive Services.
``Sec. 3132. Task Force on Community Preventive Services.

             ``Subtitle D--Prevention and Wellness Research

``Sec. 3141. Prevention and wellness research activity coordination.
``Sec. 3142. Community prevention and wellness research grants.
``Sec. 3143. Research on subsidies and rewards to encourage wellness 
              and healthy behaviors.

  ``Subtitle E--Delivery of Community Prevention and Wellness Services

``Sec. 3151. Community prevention and wellness services grants.

            ``Subtitle F--Core Public Health Infrastructure

``Sec. 3161. Core public health infrastructure for State, local, and 
              tribal health departments.
``Sec. 3162. Core public health infrastructure and activities for CDC.

                    ``Subtitle G--General Provisions

``Sec. 3171. Definitions.

                   TITLE IV--QUALITY AND SURVEILLANCE

Sec. 2401. Implementation of best practices in the delivery of health 
              care.
Sec. 2402. Assistant Secretary for Health Information.
Sec. 2403. Authorization of appropriations.

                       TITLE V--OTHER PROVISIONS

 Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program 
                               Integrity

Sec. 2501. Expanded participation in 340B program.
Sec. 2502. Improvements to 340B program integrity.
Sec. 2503. Effective date.

                          Subtitle B--Programs

                 Part 1--Grants for Clinics and Centers

Sec. 2511. School-based health clinics.
Sec. 2512. Nurse-Managed health centers.
Sec. 2513. Federally qualified behavioral health centers.

                      Part 2--Other Grant Programs

Sec. 2521. Comprehensive programs to provide education to nurses and 
              create a pipeline to nursing.
Sec. 2522. Mental and behavioral health training.
Sec. 2523. Reauthorization of telehealth and telemedicine grant 
              programs.
Sec. 2524. No child left unimmunized against influenza: demonstration 
              program using elementary and secondary schools as 
              influenza vaccination centers.
Sec. 2525. Extension of Wisewoman Program.
Sec. 2526. Healthy teen initiative to prevent teen pregnancy.
Sec. 2527. National training initiatives on autism spectrum disorders.
Sec. 2528. Implementation of medication management services in 
              treatment of chronic diseases.
Sec. 2529. Postpartum depression.
Sec. 2530. Grants to promote positive health behaviors and outcomes.
Sec. 2531. Medical liability alternatives.
Sec. 2532. Infant mortality pilot programs.
Sec. 2533. Secondary school health sciences training program.
Sec. 2534. Community-based collaborative care networks.
Sec. 2535. Community-based overweight and obesity prevention program.
Sec. 2536. Reducing student-to-school nurse ratios.

[[Page 27346]]

Sec. 2537. Medical-legal partnerships.
Sec. 2538. Screening, Brief Intervention, referral, and treatment for 
              mental health and substance abuse disorders.
Sec. 2539. Grants to assist in developing medical schools in federally-
              designated health professional shortage areas.

                Part 3--Emergency Care-Related Programs

Sec. 2551. Trauma care centers.
Sec. 2552. Emergency care coordination.
Sec. 2553. Pilot programs to improve emergency medical care.
Sec. 2554. Assisting veterans with military emergency medical training 
              to become State-licensed or certified emergency medical 
              technicians (EMTs).
Sec. 2555. Dental emergency responders: public health and medical 
              response.
Sec. 2556. Dental emergency responders: homeland security.

               Part 4--Pain Care and Management Programs

Sec. 2561. Institute of Medicine Conference on Pain.
Sec. 2562. Pain research at National Institutes of Health.
Sec. 2563. Public awareness campaign on pain management.

                Subtitle C--Food and Drug Administration

                           Part 1--In General

Sec. 2571. National medical device registry.
Sec. 2572. Nutrition labeling of standard menu items at chain 
              restaurants and of articles of food sold from vending 
              machines.
Sec. 2573. Protecting consumer access to generic drugs.

                          Part 2--Biosimilars

Sec. 2575. Licensure pathway for biosimilar biological products.
Sec. 2576. Fees relating to biosimilar biological products.
Sec. 2577. Amendments to certain patent provisions.

     Subtitle D--Community Living Assistance Services and Supports

Sec. 2581. Establishment of national voluntary insurance program for 
              purchasing community living assistance services and 
              support (CLASS program).

    ``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

``Sec. 3201. Purpose.
``Sec. 3202. Definitions.
``Sec. 3203. CLASS Independence Benefit Plan.
``Sec. 3204. Enrollment and disenrollment requirements.
``Sec. 3205. Benefits.
``Sec. 3206. CLASS Independence Fund.
``Sec. 3207. CLASS Independence Advisory Council.
``Sec. 3208. Regulations; annual report.
``Sec. 3209. Inspector General's report.

                       Subtitle E--Miscellaneous

Sec. 2585. States failing to adhere to certain employment obligations.
Sec. 2586. Health centers under Public Health Service Act; liability 
              protections for volunteer practitioners.
Sec. 2587. Report to Congress on the current state of parasitic 
              diseases that have been overlooked among the poorest 
              Americans.
Sec. 2588. Office of Women's Health.
Sec. 2588A. Offices of Minority Health.
Sec. 2589. Long-Term Care and Family Caregiver Support.
Sec. 2590. Web site on health care labor market and related educational 
              and training opportunities.
Sec. 2591. Online health workforce training programs.
Sec. 2592. Access for individuals with disabilities.
Sec. 2593. Duplicative Grant programs.
Sec. 2594. Diabetes screening collaboration and outreach program.
Sec. 2595. Improvement of vital statistics collection.
Sec. 2596. National health service corps demonstration on incentive 
              payments.

       (b) References.--Except as otherwise specified, whenever in 
     this division an amendment is expressed in terms of an 
     amendment to a section or other provision, the reference 
     shall be considered to be made to a section or other 
     provision of the Public Health Service Act (42 U.S.C. 201 et 
     seq.).

     SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.

       (a) Establishment of Funds.--
       (1) In general.--Subject to section 2003, there is hereby 
     established in the Treasury a separate account to be known as 
     the ``Public Health Investment Fund'' (referred to in this 
     section and section 2003 as the ``Fund'').
       (2) Funding.--
       (A) There shall be deposited into the Fund--
       (i) for fiscal year 2011, $4,600,000,000;
       (ii) for fiscal year 2012, $5,600,000,000;
       (iii) for fiscal year 2013, $6,900,000,000;
       (iv) for fiscal year 2014, $7,800,000,000; and
       (v) for fiscal year 2015, $9,000,000,000.
       (B) Amounts deposited into the Fund shall be derived from 
     general revenues of the Treasury only for the fiscal years 
     set forth in this section, and amounts appropriated from the 
     Fund shall remain available until expended.
       (b) Authorization of Appropriations From the Fund.--
       (1) New funding.--
       (A) In general.--Subject to section 2003, amounts in the 
     Fund are authorized to be appropriated for carrying out 
     activities under designated public health provisions.
       (B) Designated provisions.--For purposes of this paragraph, 
     the term ``designated public health provisions'' means the 
     provisions for which amounts are authorized to be 
     appropriated under section 330(s), 338(c), 338H-1, 799C, 872, 
     or 3111 of the Public Health Service Act, as added by this 
     division.
       (2) Baseline funding.--
       (A) In general.--Amounts in the Fund are authorized to be 
     appropriated (as described in paragraph (1)) for a fiscal 
     year only if (excluding any amounts in or appropriated from 
     the Fund) the amounts specified in subparagraph (B) for the 
     fiscal year involved are equal to or greater than the amounts 
     specified in subparagraph (B) for fiscal year 2008.
       (B) Amounts specified.--The amounts specified in this 
     subparagraph, with respect to a fiscal year are the amounts 
     appropriated (excluding any amounts in or appropriated from 
     the Fund) for the following:
       (i) Community health centers (including funds appropriated 
     under the authority of section 330 of the Public Health 
     Service Act (42 U.S.C. 254b)).
       (ii) The National Health Service Corps Program (including 
     funds appropriated under the authority of section 338 of such 
     Act (42 U.S.C. 254k)).
       (iii) The National Health Service Corps Scholarship and 
     Loan Repayment Programs (including funds appropriated under 
     the authority of section 338H of such Act (42 U.S.C. 254q)).
       (iv) Primary care education programs (including funds 
     appropriated under the authority of sections 736, 740, 741, 
     and 747 of such Act (42 U.S.C. 293, 293d, and 293k)).
       (v) Sections 761 and 770 of such Act (42 U.S.C. 294n and 
     295e).
       (vi) Nursing workforce development (including funds 
     appropriated under the authority of title VIII of such Act 
     (42 U.S.C. 296 et seq.)).
       (vii) The National Center for Health Statistics (including 
     funds appropriated under the authority of sections 304, 306, 
     307, and 308 of such Act (42 U.S.C. 242b, 242k, 242l, and 
     242m)).
       (viii) The Agency for Healthcare Research and Quality 
     (including funds made available under the authority of title 
     IX of such Act (42 U.S.C. 299 et seq.)).

     SEC. 2003. DEFICIT NEUTRALITY.

       (a) Availability.--Funds appropriated or made available 
     pursuant to sections 330(s), 338(c), 338H-1, 799C, 872, or 
     3111 of the Public Health Service Act, as added by this 
     division, are only available for the purposes set forth in 
     this Act. Appropriations shall not be available and are 
     precluded from obligation for any other purpose.
       (b) Estimation of Budgetary Impact.--For the purposes of 
     estimating the spending effects of this Act, the 
     authorization of appropriations from the Fund, to the extent 
     amounts in the Fund are derived from the general revenues of 
     the Treasury, shall be treated as new direct spending and 
     attributed to this Act.
       (c) Budgetary Treatment.--For the purposes of section 257 
     of the Balanced Budget and Emergency Deficit Control Act of 
     1985, the Fund, to the extent amounts in the Fund are derived 
     from the general revenues of the Treasury, and not in excess 
     of amounts subsequently appropriated from the Fund, shall be 
     deemed to be included on the list of appropriations 
     referenced under section 250(c)(17) of that Act.

                   TITLE I--COMMUNITY HEALTH CENTERS

     SEC. 2101. INCREASED FUNDING.

       Section 330 of the Public Health Service Act (42 U.S.C. 
     254b) is amended--
       (1) in subsection (r)(1)--
       (A) in subparagraph (D), by striking ``and'' at the end;
       (B) in subparagraph (E), by striking the period at the end 
     and inserting ``; and''; and
       (C) by inserting at the end the following:
       ``(F) such sums as may be necessary for each of fiscal 
     years 2013 through 2015.''; and
       (2) by inserting after subsection (r) the following:
       ``(s) Additional Funding.--For the purpose of carrying out 
     this section, in addition to any other amounts authorized to 
     be appropriated for such purpose, there are authorized to be 
     appropriated, out of any monies in the Public Health 
     Investment Fund, the following:
       ``(1) For fiscal year 2011, $1,000,000,000.
       ``(2) For fiscal year 2012, $1,500,000,000.
       ``(3) For fiscal year 2013, $2,500,000,000.
       ``(4) For fiscal year 2014, $3,000,000,000.
       ``(5) For fiscal year 2015, $4,000,000,000.''.

                          TITLE II--WORKFORCE

                   Subtitle A--Primary Care Workforce

                 PART 1--NATIONAL HEALTH SERVICE CORPS

     SEC. 2201. NATIONAL HEALTH SERVICE CORPS.

       (a) Fulfillment of Obligated Service Requirement Through 
     Half-Time Service.--

[[Page 27347]]

       (1) Waivers.--Subsection (i) of section 331 (42 U.S.C. 
     254d) is amended--
       (A) in paragraph (1), by striking ``In carrying out subpart 
     III'' and all that follows through the period and inserting 
     ``In carrying out subpart III, the Secretary may, in 
     accordance with this subsection, issue waivers to individuals 
     who have entered into a contract for obligated service under 
     the Scholarship Program or the Loan Repayment Program under 
     which the individuals are authorized to satisfy the 
     requirement of obligated service through providing clinical 
     practice that is half-time.'';
       (B) in paragraph (2)--
       (i) in subparagraphs (A)(ii) and (B), by striking ``less 
     than full time'' each place it appears and inserting ``half 
     time'';
       (ii) in subparagraphs (C) and (F), by striking ``less than 
     full-time service'' each place it appears and inserting 
     ``half-time service''; and
       (iii) by amending subparagraphs (D) and (E) to read as 
     follows:
       ``(D) the entity and the Corps member agree in writing that 
     the Corps member will perform half-time clinical practice;
       ``(E) the Corps member agrees in writing to fulfill all of 
     the service obligations under section 338C through half-time 
     clinical practice and either--
       ``(i) double the period of obligated service that would 
     otherwise be required; or
       ``(ii) in the case of contracts entered into under section 
     338B, accept a minimum service obligation of 2 years with an 
     award amount equal to 50 percent of the amount that would 
     otherwise be payable for full-time service; and''; and
       (C) in paragraph (3), by striking ``In evaluating a 
     demonstration project described in paragraph (1)'' and 
     inserting ``In evaluating waivers issued under paragraph 
     (1)''.
       (2) Definitions.--Subsection (j) of section 331 (42 U.S.C. 
     254d) is amended by adding at the end the following:
       ``(5) The terms `full time' and `full-time' mean a minimum 
     of 40 hours per week in a clinical practice, for a minimum of 
     45 weeks per year.
       ``(6) The terms `half time' and `half-time' mean a minimum 
     of 20 hours per week (not to exceed 39 hours per week) in a 
     clinical practice, for a minimum of 45 weeks per year.''.
       (b) Reappointment to National Advisory Council.--Section 
     337(b)(1) (42 U.S.C. 254j(b)(1)) is amended by striking 
     ``Members may not be reappointed to the Council.''.
       (c) Loan Repayment Amount.--Section 338B(g)(2)(A) (42 
     U.S.C. 254l-1(g)(2)(A)) is amended by striking ``$35,000'' 
     and inserting ``$50,000, plus, beginning with fiscal year 
     2012, an amount determined by the Secretary on an annual 
     basis to reflect inflation,''.
       (d) Treatment of Teaching as Obligated Service.--Subsection 
     (a) of section 338C (42 U.S.C. 254m) is amended by adding at 
     the end the following: ``The Secretary may treat teaching as 
     clinical practice for up to 20 percent of such period of 
     obligated service.''.

     SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS.

       (a) National Health Service Corps Program.--Section 338 (42 
     U.S.C. 254k) is amended--
       (1) in subsection (a), by striking ``2012'' and inserting 
     ``2015''; and
       (2) by adding at the end the following:
       ``(c) For the purpose of carrying out this subpart, in 
     addition to any other amounts authorized to be appropriated 
     for such purpose, there are authorized to be appropriated, 
     out of any monies in the Public Health Investment Fund, the 
     following:
       ``(1) $63,000,000 for fiscal year 2011.
       ``(2) $66,000,000 for fiscal year 2012.
       ``(3) $70,000,000 for fiscal year 2013.
       ``(4) $73,000,000 for fiscal year 2014.
       ``(5) $77,000,000 for fiscal year 2015.''.
       (b) Scholarship and Loan Repayment Programs.--Subpart III 
     of part D of title III of the Public Health Service Act (42 
     U.S.C. 254l et seq.) is amended--
       (1) in section 338H(a)--
       (A) in paragraph (4), by striking ``and'' at the end;
       (B) in paragraph (5), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(6) for each of fiscal years 2013 through 2015, such sums 
     as may be necessary.''; and
       (2) by inserting after section 338H the following:

     ``SEC. 338H-1. ADDITIONAL FUNDING.

       ``For the purpose of carrying out this subpart, in addition 
     to any other amounts authorized to be appropriated for such 
     purpose, there are authorized to be appropriated, out of any 
     monies in the Public Health Investment Fund, the following:
       ``(1) $254,000,000 for fiscal year 2011.
       ``(2) $266,000,000 for fiscal year 2012.
       ``(3) $278,000,000 for fiscal year 2013.
       ``(4) $292,000,000 for fiscal year 2014.
       ``(5) $306,000,000 for fiscal year 2015.''.

            PART 2--PROMOTION OF PRIMARY CARE AND DENTISTRY

     SEC. 2211. FRONTLINE HEALTH PROVIDERS.

       Part D of title III (42 U.S.C. 254b et seq.) is amended by 
     adding at the end the following:

             ``Subpart XI--Health Professional Needs Areas

     ``SEC. 340H. IN GENERAL.

       ``(a) Program.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall establish a program, to be known as the 
     Frontline Health Providers Loan Repayment Program, to address 
     unmet health care needs in health professional needs areas 
     through loan repayments under section 340I.
       ``(b) Designation of Health Professional Needs Areas.--
       ``(1) In general.--In this subpart, the term `health 
     professional needs area' means an area, population, or 
     facility that is designated by the Secretary in accordance 
     with paragraph (2).
       ``(2) Designation.--To be designated by the Secretary as a 
     health professional needs area under this subpart:
       ``(A) In the case of an area, the area must be a rational 
     area for the delivery of health services.
       ``(B) The area, population, or facility must have, in one 
     or more health disciplines, specialties, or subspecialties 
     for the population served, as determined by the Secretary--
       ``(i) insufficient capacity of health professionals; or
       ``(ii) high needs for health services, including services 
     to address health disparities.
       ``(C) With respect to the delivery of primary health 
     services, the area, population, or facility must not include 
     a health professional shortage area (as designated under 
     section 332), except that the area, population, or facility 
     may include such a health professional shortage area in which 
     there is an unmet need for such services.
       ``(c) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1) hold a degree in a course of study or program 
     (approved by the Secretary) from a school defined in section 
     799B(1)(A) (other than a school of public health);
       ``(2) hold a degree in a course of study or program 
     (approved by the Secretary) from a school or program defined 
     in subparagraph (C), (D), or (E)(4) of section 799B(1), as 
     designated by the Secretary;
       ``(3) be enrolled as a full-time student--
       ``(A) in a school or program defined in subparagraph (C), 
     (D), or (E)(4) of section 799B(1), as designated by the 
     Secretary, or a school described in paragraph (1); and
       ``(B) in the final year of a course of study or program, 
     offered by such school or program and approved by the 
     Secretary, leading to a degree in a discipline referred to in 
     subparagraph (A) (other than a graduate degree in public 
     health), (C), (D), or (E)(4) of section 799B(1);
       ``(4) be a practitioner described in section 1842(b)(18)(C) 
     or 1848(k)(3)(B)(iii) or (iv) of the Social Security Act; or
       ``(5) be a practitioner in the field of respiratory 
     therapy, medical technology, or radiologic technology.
       ``(d) Definitions.--In this subpart:
       ``(1) The term `health disparities' has the meaning given 
     to the term in section 3171.
       ``(2) The term `primary health services' has the meaning 
     given to such term in section 331(a)(3)(D).
       ``SEC. 340I. LOAN REPAYMENTS.
       ``(a) Loan Repayments.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall enter into contracts with individuals 
     under which--
       ``(1) the individual agrees--
       ``(A) to serve as a full-time primary health services 
     provider or as a full-time or part-time provider of other 
     health services for a period of time equal to 2 years or such 
     longer period as the individual may agree to;
       ``(B) to serve in a health professional needs area in a 
     health discipline, specialty, or a subspecialty for which the 
     area, population, or facility is designated as a health 
     professional needs area under section 340H; and
       ``(C) in the case of an individual described in section 
     340H(c)(3) who is in the final year of study and who has 
     accepted employment as a primary health services provider or 
     provider of other health services in accordance with 
     subparagraphs (A) and (B), to complete the education or 
     training and maintain an acceptable level of academic 
     standing (as determined by the educational institution 
     offering the course of study or training); and
       ``(2) the Secretary agrees to pay, for each year of such 
     service, an amount on the principal and interest of the 
     undergraduate or graduate educational loans (or both) of the 
     individual that is not more than 50 percent of the average 
     award made under the National Health Service Corps Loan 
     Repayment Program under subpart III in that year.
       ``(b) Practice Setting.--A contract entered into under this 
     section shall allow the individual receiving the loan 
     repayment to satisfy the service requirement described in 
     subsection (a)(1) through employment in a solo or group 
     practice, a clinic, an accredited public or private nonprofit 
     hospital, or any other health care entity, as deemed 
     appropriate by the Secretary.
       ``(c) Application of Certain Provisions.--The provisions of 
     subpart III of part D shall, except as inconsistent with this 
     section, apply to the loan repayment program under this 
     subpart in the same manner and to the same extent as such 
     provisions apply to the National Health Service Corps Loan 
     Repayment Program established under section 338B.
       ``(d) Insufficient Number of Applicants.--If there are an 
     insufficient number of applicants for loan repayments under 
     this section to obligate all appropriated funds,

[[Page 27348]]

     the Secretary shall transfer the unobligated funds to the 
     National Health Service Corps for the purpose of recruiting 
     applicants and entering into contracts with individuals so as 
     to ensure a sufficient number of participants in the National 
     Health Service Corps for the following year.

     ``SEC. 340J. REPORT.

       ``The Secretary shall submit to the Congress an annual 
     report on the program carried out under this subpart.

     ``SEC. 340K. ALLOCATION.

       ``Of the amount of funds obligated under this subpart each 
     fiscal year for loan repayments--
       ``(1) 90 percent shall be for physicians and other health 
     professionals providing primary health services; and
       ``(2) 10 percent shall be for health professionals not 
     described in paragraph (1).''.

     SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS.

       (a) In General.--Section 735 (42 U.S.C. 292y) is amended--
       (1) by redesignating subsection (f) as subsection (g); and
       (2) by inserting after subsection (e) the following:
       ``(f) Determination of Financial Need.--The Secretary--
       ``(1) may require, or authorize a school or other entity to 
     require, the submission of financial information to determine 
     the financial resources available to any individual seeking 
     assistance under this subpart; and
       ``(2) shall take into account the extent to which such 
     individual is financially independent in determining whether 
     to require or authorize the submission of such information 
     regarding such individual's family members.''.
       (b) Revised Guidelines.--The Secretary of Health and Human 
     Services shall--
       (1) strike the second sentence of section 57.206(b)(1) of 
     title 42, Code of Federal Regulations; and
       (2) make such other revisions to guidelines and regulations 
     in effect as of the date of the enactment of this Act as may 
     be necessary for consistency with the amendments made by 
     paragraph (1).

     SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL 
                   MEDICINE, GENERAL PEDIATRICS, GERIATRICS, AND 
                   PHYSICIAN ASSISTANTS.

       Section 747 (42 U.S.C. 293k) is amended--
       (1) by amending the section heading to read as follows: 
     ``PRIMARY CARE TRAINING AND ENHANCEMENT'';
       (2) by redesignating subsection (e) as subsection (g); and
       (3) by striking subsections (a) through (d) and inserting 
     the following:
       ``(a) Program.--The Secretary shall establish a primary 
     care training and capacity building program consisting of 
     awarding grants and contracts under subsections (b) and (c).
       ``(b) Support and Development of Primary Care Training 
     Programs.--
       ``(1) In general.--The Secretary shall make grants to, or 
     enter into contracts with, eligible entities--
       ``(A) to plan, develop, operate, or participate in an 
     accredited professional training program, including an 
     accredited residency or internship program, in the field of 
     family medicine, general internal medicine, general 
     pediatrics, or geriatrics for medical students, interns, 
     residents, or practicing physicians;
       ``(B) to provide financial assistance in the form of 
     traineeships and fellowships to medical students, interns, 
     residents, or practicing physicians, who are participants in 
     any such program, and who plan to specialize or work in 
     family medicine, general internal medicine, general 
     pediatrics, or geriatrics;
       ``(C) to plan, develop, operate, or participate in an 
     accredited program for the training of physicians who plan to 
     teach in family medicine, general internal medicine, general 
     pediatrics, or geriatrics training programs including in 
     community-based settings;
       ``(D) to provide financial assistance in the form of 
     traineeships and fellowships to practicing physicians who are 
     participants in any such programs and who plan to teach in a 
     family medicine, general internal medicine, general 
     pediatrics, or geriatrics training program; and
       ``(E) to plan, develop, operate, or participate in an 
     accredited program for physician assistant education, and for 
     the training of individuals who plan to teach in programs to 
     provide such training.
       ``(2) Eligibility.--To be eligible for a grant or contract 
     under paragraph (1), an entity shall be--
       ``(A) an accredited school of medicine or osteopathic 
     medicine, public or nonprofit private hospital, or physician 
     assistant training program;
       ``(B) a public or private nonprofit entity; or
       ``(C) a consortium of 2 or more entities described in 
     subparagraphs (A) and (B).
       ``(c) Capacity Building in Primary Care.--
       ``(1) In general.--The Secretary shall make grants to or 
     enter into contracts with eligible entities to establish, 
     maintain, or improve--
       ``(A) academic administrative units (including departments, 
     divisions, or other appropriate units) in the specialties of 
     family medicine, general internal medicine, general 
     pediatrics, or geriatrics; or
       ``(B) programs that improve clinical teaching in such 
     specialties.
       ``(2) Eligibility.--To be eligible for a grant or contract 
     under paragraph (1), an entity shall be an accredited school 
     of medicine or osteopathic medicine.
       ``(d) Preference.--In awarding grants or contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Training a high or significantly improved percentage 
     of health professionals who provide primary care.
       ``(2) Training individuals who are from disadvantaged 
     backgrounds (including racial and ethnic minorities 
     underrepresented among primary care professionals).
       ``(3) A high rate of placing graduates in practice settings 
     having the principal focus of serving in underserved areas or 
     populations experiencing health disparities (including 
     serving patients eligible for medical assistance under title 
     XIX of the Social Security Act or for child health assistance 
     under title XXI of such Act or those with special health care 
     needs).
       ``(4) Supporting teaching programs that address the health 
     care needs of vulnerable populations.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.
       ``(f) Definition.--In this section, the term `health 
     disparities' has the meaning given the term in section 
     3171.''.

     SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED 
                   SETTINGS.

       Title VII (42 U.S.C. 292 et seq.) is amended--
       (1) by redesignating section 748 as 749A; and
       (2) by inserting after section 747 the following:

     ``SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED 
                   SETTINGS.

       ``(a) Program.--The Secretary shall establish a program for 
     the training of medical residents in community-based settings 
     consisting of awarding grants and contracts under this 
     section.
       ``(b) Development and Operation of Community-Based 
     Programs.--The Secretary shall make grants to, or enter into 
     contracts with, eligible entities--
       ``(1) to plan and develop a new primary care residency 
     training program, which may include--
       ``(A) planning and developing curricula;
       ``(B) recruiting and training residents and faculty; and
       ``(C) other activities designated to result in 
     accreditation of such a program; or
       ``(2) to operate or participate in an established primary 
     care residency training program, which may include--
       ``(A) planning and developing curricula;
       ``(B) recruitment and training of residents; and
       ``(C) retention of faculty.
       ``(c) Eligible Entity.--To be eligible to receive a grant 
     or contract under subsection (b), an entity shall--
       ``(1) be designated as a recipient of payment for the 
     direct costs of medical education under section 1886(k) of 
     the Social Security Act;
       ``(2) be designated as an approved teaching health center 
     under section 1502(d) of the Affordable Health Care for 
     America Act and continuing to participate in the 
     demonstration project under such section;
       ``(3) be an applicant for designation described in 
     paragraph (1) or (2) and have demonstrated to the Secretary 
     appropriate involvement of an accredited teaching hospital to 
     carry out the inpatient responsibilities associated with a 
     primary care residency training program; or
       ``(4) be eligible to be designated as described in 
     paragraph (1) or (2), not be an applicant as described in 
     paragraph (3), and have demonstrated appropriate involvement 
     of an accredited teaching hospital to carry out the inpatient 
     responsibilities associated with a primary care residency 
     training program.
       ``(d) Preferences.--In awarding grants and contracts under 
     paragraph (1) or (2) of subsection (b), the Secretary shall 
     give preference to entities that--
       ``(1) support teaching programs that address the health 
     care needs of vulnerable populations; or
       ``(2) are a Federally qualified health center (as defined 
     in section 1861(aa)(4) of the Social Security Act) or a rural 
     health clinic (as defined in section 1861(aa)(2) of such 
     Act).
       ``(e) Additional Preferences for Established Programs.--In 
     awarding grants and contracts under subsection (b)(2), the 
     Secretary shall give preference to entities that have a 
     demonstrated record of training--
       ``(1) a high or significantly improved percentage of health 
     professionals who provide primary care;
       ``(2) individuals who are from disadvantaged backgrounds 
     (including racial and ethnic minorities underrepresented 
     among primary care professionals); or
       ``(3) individuals who practice in settings having the 
     principal focus of serving underserved areas or populations 
     experiencing health disparities (including serving patients

[[Page 27349]]

     eligible for medical assistance under title XIX of the Social 
     Security Act or for child health assistance under title XXI 
     of such Act or those with special health care needs).
       ``(f) Period of Awards.--
       ``(1) In general.--The period of a grant or contract under 
     this section--
       ``(A) shall not exceed 3 years for awards under subsection 
     (b)(1); and
       ``(B) shall not exceed 5 years for awards under subsection 
     (b)(2).
       ``(2) Special rules.--
       ``(A) An award of a grant or contract under subsection 
     (b)(1) shall not be renewed.
       ``(B) The period of a grant or contract awarded to an 
     entity under subsection (b)(2) shall not overlap with the 
     period of any grant or contact awarded to the same entity 
     under subsection (b)(1).
       ``(g) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.
       ``(h) Definitions.--In this section:
       ``(1) Health disparities.--The term `health disparities' 
     has the meaning given the term in section 3171.
       ``(2) Primary care resident.--The term `primary care 
     resident' has the meaning given the term in section 
     1886(h)(5)(H) of the Social Security Act.
       ``(3) Primary care residency training program.--The term 
     `primary care residency training program' means an approved 
     medical residency training program described in section 
     1886(h)(5)(A) of the Social Security Act for primary care 
     residents that is--
       ``(A) in the case of entities seeking awards under 
     subsection (b)(1), actively applying to be accredited by the 
     Accreditation Council for Graduate Medical Education or the 
     American Osteopathic Association; or
       ``(B) in the case of entities seeking awards under 
     subsection (b)(2), so accredited.
       ``(i) Allocation of Funds.--Of the amount appropriated 
     pursuant to section 799C(a) for a fiscal year, not more than 
     17 percent of such amount shall be made available to carry 
     out this section.''.

     SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH 
                   DENTISTS AND DENTAL HYGIENISTS.

       Title VII (42 U.S.C. 292 et seq.) is amended--
       (1) in section 791(a)(1), by striking ``747 and 750'' and 
     inserting ``747, 749, and 750''; and
       (2) by inserting after section 748, as added, the 
     following:

     ``SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC 
                   HEALTH DENTISTS AND DENTAL HYGIENISTS.

       ``(a) Program.--The Secretary shall establish a training 
     program for oral health professionals consisting of awarding 
     grants and contracts under this section.
       ``(b) Support and Development of Oral Health Training 
     Programs.--The Secretary shall make grants to, or enter into 
     contracts with, eligible entities--
       ``(1) to plan, develop, operate, or participate in an 
     accredited professional training program for oral health 
     professionals;
       ``(2) to provide financial assistance to oral health 
     professionals who are in need thereof, who are participants 
     in any such program, and who plan to work in general, 
     pediatric, or public health dentistry, or dental hygiene;
       ``(3) to plan, develop, operate, or participate in a 
     program for the training of oral health professionals who 
     plan to teach in general, pediatric, or public health 
     dentistry, or dental hygiene;
       ``(4) to provide financial assistance in the form of 
     traineeships and fellowships to oral health professionals who 
     plan to teach in general, pediatric, or public health 
     dentistry or dental hygiene;
       ``(5) to establish, maintain, or improve--
       ``(A) academic administrative units (including departments, 
     divisions, or other appropriate units) in the specialties of 
     general, pediatric, or public health dentistry; or
       ``(B) programs that improve clinical teaching in such 
     specialties;
       ``(6) to plan, develop, operate, or participate in 
     predoctoral and postdoctoral training in general, pediatric, 
     or public health dentistry programs;
       ``(7) to plan, develop, operate, or participate in a loan 
     repayment program for full-time faculty in a program of 
     general, pediatric, or public health dentistry; and
       ``(8) to provide technical assistance to pediatric dental 
     training programs in developing and implementing instruction 
     regarding the oral health status, dental care needs, and 
     risk-based clinical disease management of all pediatric 
     populations with an emphasis on underserved children.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under this section, an entity shall be--
       ``(1) an accredited school of dentistry, training program 
     in dental hygiene, or public or nonprofit private hospital;
       ``(2) a training program in dental hygiene at an accredited 
     institution of higher education;
       ``(3) a public or private nonprofit entity; or
       ``(4) a consortium of--
       ``(A) 1 or more of the entities described in paragraphs (1) 
     through (3); and
       ``(B) an accredited school of public health.
       ``(d) Preference.--In awarding grants or contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Training a high or significantly improved percentage 
     of oral health professionals who practice general, pediatric, 
     or public health dentistry.
       ``(2) Training individuals who are from disadvantaged 
     backgrounds (including racial and ethnic minorities 
     underrepresented among oral health professionals).
       ``(3) A high rate of placing graduates in practice settings 
     having the principal focus of serving in underserved areas or 
     populations experiencing health disparities (including 
     serving patients eligible for medical assistance under title 
     XIX of the Social Security Act or for child health assistance 
     under title XXI of such Act or those with special health care 
     needs).
       ``(4) Supporting teaching programs that address the oral 
     health needs of vulnerable populations.
       ``(5) Providing instruction regarding the oral health 
     status, oral health care needs, and risk-based clinical 
     disease management of all pediatric populations with an 
     emphasis on underserved children.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.
       ``(f) Definitions.--In this section:
       ``(1) The term `health disparities' has the meaning given 
     the term in section 3171.
       ``(2) The term `oral health professional' means an 
     individual training or practicing--
       ``(A) in general dentistry, pediatric dentistry, public 
     health dentistry, or dental hygiene; or
       ``(B) another oral health specialty, as deemed appropriate 
     by the Secretary.''.

     SEC. 2216. AUTHORIZATION OF APPROPRIATIONS.

       (a) In General.--Part F of title VII (42 U.S.C. 295j et 
     seq.) is amended by adding at the end the following:

     ``SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

       ``(a) Promotion of Primary Care and Dentistry.--For the 
     purpose of carrying out subpart XI of part D of title III and 
     sections 747, 748, and 749, in addition to any other amounts 
     authorized to be appropriated for such purpose, there are 
     authorized to be appropriated, out of any monies in the 
     Public Health Investment Fund, the following:
       ``(1) $240,000,000 for fiscal year 2011.
       ``(2) $253,000,000 for fiscal year 2012.
       ``(3) $265,000,000 for fiscal year 2013.
       ``(4) $278,000,000 for fiscal year 2014.
       ``(5) $292,000,000 for fiscal year 2015.''.
       (b) Existing Authorization of Appropriations.--Subsection 
     (g)(1), as so redesignated, of section 747 (42 U.S.C. 293k) 
     is amended by striking ``2002'' and inserting ``2015''.

     SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS AND LOAN 
                   REPAYMENTS.

       (a) Study.--The Comptroller General of the United States 
     shall conduct a study to determine the effectiveness of 
     scholarship and loan repayment programs under subparts III 
     and XI of part D of title III of the Public Health Service 
     Act, as amended or added by sections 2201 and 2211, including 
     whether scholarships or loan repayments are more effective 
     in--
       (1) incentivizing physicians, and other providers, to 
     pursue careers in primary care specialties;
       (2) retaining such primary care providers; and
       (3) encouraging such primary care providers to practice in 
     underserved areas.
       (b) Report.--Not later than 12 months after the date of the 
     enactment of this Act, the Comptroller General shall submit 
     to the Congress a report on the results of the study under 
     subsection (a).

                     Subtitle B--Nursing Workforce

     SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.

       (a) Definitions.--Section 801 (42 U.S.C. 296 et seq.) is 
     amended--
       (1) in paragraph (1), by inserting ``nurse-managed health 
     centers,'' after ``nursing centers,''; and
       (2) by adding at the end the following:
       ``(16) Nurse-managed health center.--The term `nurse-
     managed health center'--
       ``(A) means a nurse-practice arrangement, managed by one or 
     more advanced practice nurses, that provides primary care or 
     wellness services to underserved or vulnerable populations 
     and is associated with an accredited school of nursing, 
     Federally qualified health center, or independent nonprofit 
     health or social services agency; and
       ``(B) shall not be construed as changing State law 
     requirements applicable to an advanced practice nurse or the 
     authorized scope of practice of such a nurse.''.
       (b) Grants for Health Professions Education.--Title VIII 
     (42 U.S.C. 296 et seq.) is amended by striking section 807.
       (c) Reports.--Part A of title VIII (42 U.S.C. 296 et seq.) 
     is amended by adding at the end the following:

     ``SEC. 809. REPORTS.

       ``The Secretary shall submit to the Congress a separate 
     annual report on the activities carried out under each of 
     sections 811, 821, 836, 846A, and 861.''.
       (d) Advanced Education Nursing Grants.--Section 811(f) (42 
     U.S.C. 296j(f)) is amended--
       (1) by striking paragraph (2);
       (2) by redesignating paragraph (3) as paragraph (2); and
       (3) in paragraph (2), as so redesignated, by striking 
     ``that agrees'' and all that follows

[[Page 27350]]

     through the end and inserting: ``that agrees to expend the 
     award--
       ``(A) to train advanced education nurses who will practice 
     in health professional shortage areas designated under 
     section 332; or
       ``(B) to increase diversity among advanced education 
     nurses.''.
       (e) Nurse Education, Practice, and Retention Grants.--
     Section 831 (42 U.S.C. 296p) is amended--
       (1) in subsection (b), by amending paragraph (3) to read as 
     follows:
       ``(3) providing coordinated care, quality care, and other 
     skills needed to practice nursing; or''; and
       (2) by striking subsection (e) and redesignating 
     subsections (f) through (h) as subsections (e) through (g), 
     respectively.
       (f) Student Loans.--Subsection (a) of section 836 (42 
     U.S.C. 297b) is amended--
       (1) by striking ``$2,500'' and inserting ``$3,300'';
       (2) by striking ``$4,000'' and inserting ``$5,200'';
       (3) by striking ``$13,000'' and inserting ``$17,000''; and
       (4) by adding at the end the following: ``Beginning with 
     fiscal year 2012, the dollar amounts specified in this 
     subsection shall be adjusted by an amount determined by the 
     Secretary on an annual basis to reflect inflation.''.
       (g) Loan Repayment.--Section 846 (42 U.S.C. 297n) is 
     amended--
       (1) in subsection (a), by amending paragraph (3) to read as 
     follows:
       ``(3) who enters into an agreement with the Secretary to 
     serve for a period of not less than 2 years--
       ``(A) as a nurse at a health care facility with a critical 
     shortage of nurses; or
       ``(B) as a faculty member at an accredited school of 
     nursing;''; and
       (2) in subsection (g)(1), by striking ``to provide health 
     services'' each place it appears and inserting ``to provide 
     health services or serve as a faculty member''.
       (h) Nurse Faculty Loan Program.--Paragraph (2) of section 
     846A(c) (42 U.S.C. 297n-1(c)) is amended by striking 
     ``$30,000'' and all that follows through the semicolon and 
     inserting ``$35,000, plus, beginning with fiscal year 2012, 
     an amount determined by the Secretary on an annual basis to 
     reflect inflation;''.
       (i) Public Service Announcements.--Title VIII (42 U.S.C. 
     296 et seq.) is amended by striking part H.
       (j) Technical and Conforming Amendments.--Title VIII (42 
     U.S.C. 296 et seq.) is amended--
       (1) by moving section 810 (relating to prohibition against 
     discrimination by schools on the basis of sex) so that it 
     follows section 809, as added by subsection (c);
       (2) in sections 835, 836, 838, 840, and 842, by striking 
     the term ``this subpart'' each place it appears and inserting 
     ``this part'';
       (3) in section 836(h), by striking the last sentence;
       (4) in section 836, by redesignating subsection (l) as 
     subsection (k);
       (5) in section 839, by striking ``839'' and all that 
     follows through ``(a)'' and inserting ``839. (a)'';
       (6) in section 835(b), by striking ``841'' each place it 
     appears and inserting ``871'';
       (7) by redesignating section 841 as section 871, moving 
     part F to the end of the title, and redesignating such part 
     as part H;
       (8) in part G--
       (A) by redesignating section 845 as section 851; and
       (B) by redesignating part G as part F; and
       (9) in part I--
       (A) by redesignating section 855 as section 861; and
       (B) by redesignating part I as part G.
       (k) Funding.--
       (1) In general.--Part H, as redesignated, of title VIII is 
     amended by adding at the end the following:

     ``SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

       ``For the purpose of carrying out this title, in addition 
     to any other amounts authorized to be appropriated for such 
     purpose, there are authorized to be appropriated, out of any 
     monies in the Public Health Investment Fund, the following:
       ``(1) $115,000,000 for fiscal year 2011.
       ``(2) $122,000,000 for fiscal year 2012.
       ``(3) $127,000,000 for fiscal year 2013.
       ``(4) $134,000,000 for fiscal year 2014.
       ``(5) $140,000,000 for fiscal year 2015.''.
       (2) Existing authorizations of appropriations.--
       (A) Sections 831, 846, 846a, and 861.--Sections 831(g) (as 
     so redesignated), 846(i)(1) (42 U.S.C. 297n(i)(1)), 846A(f) 
     (42 U.S.C. 297n-1(f)), and 861(e) (as so redesignated) are 
     amended by striking ``2007'' each place it appears and 
     inserting ``2015''.
       (B) Section 871.--Section 871, as so redesignated by 
     subsection (j), is amended to read as follows:

     ``SEC. 871. FUNDING.

       ``For the purpose of carrying out parts B, C, and D 
     (subject to section 851(g)), there are authorized to be 
     appropriated such sums as may be necessary for each fiscal 
     year through fiscal year 2015.''.

                  Subtitle C--Public Health Workforce

     SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS.

       Part D of title III (42 U.S.C. 254b et seq.), as amended by 
     section 2211, is amended by adding at the end the following:

                 ``Subpart XII--Public Health Workforce

     ``SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.

       ``(a) Establishment.--There is established, within the 
     Service, the Public Health Workforce Corps (in this subpart 
     referred to as the `Corps'), for the purpose of ensuring an 
     adequate supply of public health professionals throughout the 
     Nation. The Corps shall consist of--
       ``(1) such officers of the Regular and Reserve Corps of the 
     Service as the Secretary may designate;
       ``(2) such civilian employees of the United States as the 
     Secretary may appoint; and
       ``(3) such other individuals who are not employees of the 
     United States.
       ``(b) Administration.--Except as provided in subsection 
     (c), the Secretary shall carry out this subpart acting 
     through the Administrator of the Health Resources and 
     Services Administration.
       ``(c) Placement and Assignment.--The Secretary, acting 
     through the Director of the Centers for Disease Control and 
     Prevention, shall develop a methodology for placing and 
     assigning Corps participants as public health professionals. 
     Such methodology may allow for placing and assigning such 
     participants in State, local, and tribal health departments 
     and Federally qualified health centers (as defined in section 
     1861(aa)(4) of the Social Security Act).
       ``(d) Application of Certain Provisions.--The provisions of 
     subpart II shall, except as inconsistent with this subpart, 
     apply to the Public Health Workforce Corps in the same manner 
     and to the same extent as such provisions apply to the 
     National Health Service Corps established under section 331.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the programs carried out under this 
     subpart.

     ``SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.

       ``(a) Establishment.--The Secretary shall establish the 
     Public Health Workforce Scholarship Program (referred to in 
     this section as the `Program') for the purpose described in 
     section 340L(a).
       ``(b) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1)(A) be accepted for enrollment, or be enrolled, as a 
     full-time or part-time student in a course of study or 
     program (approved by the Secretary) at an accredited graduate 
     school or program of public health; or
       ``(B) have demonstrated expertise in public health and be 
     accepted for enrollment, or be enrolled, as a full-time or 
     part-time student in a course of study or program (approved 
     by the Secretary) at--
       ``(i) an accredited graduate school or program of nursing; 
     health administration, management, or policy; preventive 
     medicine; laboratory science; veterinary medicine; or dental 
     medicine; or
       ``(ii) another accredited graduate school or program, as 
     deemed appropriate by the Secretary;
       ``(2) be eligible for, or hold, an appointment as a 
     commissioned officer in the Regular or Reserve Corps of the 
     Service or be eligible for selection for civilian service in 
     the Corps; and
       ``(3) sign and submit to the Secretary a written contract 
     (described in subsection (c)) to serve full-time as a public 
     health professional, upon the completion of the course of 
     study or program involved, for the period of obligated 
     service described in subsection (c)(2)(E).
       ``(c) Contract.--The written contract between the Secretary 
     and an individual under subsection (b)(3) shall contain--
       ``(1) an agreement on the part of the Secretary that the 
     Secretary will--
       ``(A) provide the individual with a scholarship for a 
     period of years (not to exceed 4 academic years) during which 
     the individual shall pursue an approved course of study or 
     program to prepare the individual to serve in the public 
     health workforce; and
       ``(B) accept (subject to the availability of appropriated 
     funds) the individual into the Corps;
       ``(2) an agreement on the part of the individual that the 
     individual will--
       ``(A) accept provision of such scholarship to the 
     individual;
       ``(B) maintain full-time or part-time enrollment in the 
     approved course of study or program described in subsection 
     (b)(1) until the individual completes that course of study or 
     program;
       ``(C) while enrolled in the approved course of study or 
     program, maintain an acceptable level of academic standing 
     (as determined by the educational institution offering such 
     course of study or program);
       ``(D) if applicable, complete a residency or internship; 
     and
       ``(E) serve full-time as a public health professional for a 
     period of time equal to the greater of--
       ``(i) 1 year for each academic year for which the 
     individual was provided a scholarship under the Program; or
       ``(ii) 2 years; and
       ``(3) an agreement by both parties as to the nature and 
     extent of the scholarship assistance, which may include--
       ``(A) payment of reasonable educational expenses of the 
     individual, including tuition,

[[Page 27351]]

     fees, books, equipment, and laboratory expenses; and
       ``(B) payment of a stipend of not more than $1,269 (plus, 
     beginning with fiscal year 2012, an amount determined by the 
     Secretary on an annual basis to reflect inflation) per month 
     for each month of the academic year involved, with the dollar 
     amount of such a stipend determined by the Secretary taking 
     into consideration whether the individual is enrolled full-
     time or part-time.
       ``(d) Application of Certain Provisions.--The provisions of 
     subpart III shall, except as inconsistent with this subpart, 
     apply to the scholarship program under this section in the 
     same manner and to the same extent as such provisions apply 
     to the National Health Service Corps Scholarship Program 
     established under section 338A.

     ``SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.

       ``(a) Establishment.--The Secretary shall establish the 
     Public Health Workforce Loan Repayment Program (referred to 
     in this section as the `Program') for the purpose described 
     in section 340L(a).
       ``(b) Eligibility.--To be eligible to participate in the 
     Program, an individual shall--
       ``(1)(A) have a graduate degree from an accredited school 
     or program of public health;
       ``(B) have demonstrated expertise in public health and have 
     a graduate degree in a course of study or program (approved 
     by the Secretary) from--
       ``(i) an accredited school or program of nursing; health 
     administration, management, or policy; preventive medicine; 
     laboratory science; veterinary medicine; or dental medicine; 
     or
       ``(ii) another accredited school or program approved by the 
     Secretary; or
       ``(C) be enrolled as a full-time or part-time student in 
     the final year of a course of study or program (approved by 
     the Secretary) offered by a school or program described in 
     subparagraph (A) or (B), leading to a graduate degree;
       ``(2) be eligible for, or hold, an appointment as a 
     commissioned officer in the Regular or Reserve Corps of the 
     Service or be eligible for selection for civilian service in 
     the Corps;
       ``(3) if applicable, complete a residency or internship; 
     and
       ``(4) sign and submit to the Secretary a written contract 
     (described in subsection (c)) to serve full-time as a public 
     health professional for the period of obligated service 
     described in subsection (c)(2).
       ``(c) Contract.--The written contract between the Secretary 
     and an individual under subsection (b)(4) shall contain--
       ``(1) an agreement by the Secretary to repay on behalf of 
     the individual loans incurred by the individual in the 
     pursuit of the relevant public health workforce educational 
     degree in accordance with the terms of the contract;
       ``(2) an agreement by the individual to serve full-time as 
     a public health professional for a period of time equal to 2 
     years or such longer period as the individual may agree to; 
     and
       ``(3) in the case of an individual described in subsection 
     (b)(1)(C) who is in the final year of study and who has 
     accepted employment as a public health professional, in 
     accordance with section 340L(c), an agreement on the part of 
     the individual to complete the education or training, 
     maintain an acceptable level of academic standing (as 
     determined by the educational institution offering the course 
     of study or training), and serve the period of obligated 
     service described in paragraph (2).
       ``(d) Payments.--
       ``(1) In general.--A loan repayment provided for an 
     individual under a written contract under the Program shall 
     consist of payment, in accordance with paragraph (2), on 
     behalf of the individual of the principal, interest, and 
     related expenses on government and commercial loans received 
     by the individual regarding the undergraduate or graduate 
     education of the individual (or both), which loans were made 
     for reasonable educational expenses, including tuition, fees, 
     books, equipment, and laboratory expenses, incurred by the 
     individual.
       ``(2) Payments for years served.--
       ``(A) In general.--For each year of obligated service that 
     an individual contracts to serve under subsection (c), the 
     Secretary may pay up to $35,000 (plus, beginning with fiscal 
     year 2012, an amount determined by the Secretary on an annual 
     basis to reflect inflation) on behalf of the individual for 
     loans described in paragraph (1).
       ``(B) Repayment schedule.--Any arrangement made by the 
     Secretary for the making of loan repayments in accordance 
     with this subsection shall provide that any repayments for a 
     year of obligated service shall be made no later than the end 
     of the fiscal year in which the individual completes such 
     year of service.
       ``(e) Application of Certain Provisions.--The provisions of 
     subpart III shall, except as inconsistent with this subpart, 
     apply to the loan repayment program under this section in the 
     same manner and to the same extent as such provisions apply 
     to the National Health Service Corps Loan Repayment Program 
     established under section 338B.''.

     SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.

       Section 765 (42 U.S.C. 295) is amended to read as follows:

     ``SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.

       ``(a) Program.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     Centers for Disease Control and Prevention, shall establish a 
     public health workforce training and enhancement program 
     consisting of awarding grants and contracts under subsection 
     (b).
       ``(b) Grants and Contracts.--The Secretary shall award 
     grants to, or enter into contracts with, eligible entities--
       ``(1) to plan, develop, operate, or participate in, an 
     accredited professional training program in the field of 
     public health (including such a program in nursing; health 
     administration, management, or policy; preventive medicine; 
     laboratory science; veterinary medicine; or dental medicine) 
     for members of the public health workforce, including 
     midcareer professionals;
       ``(2) to provide financial assistance in the form of 
     traineeships and fellowships to students who are participants 
     in any such program and who plan to specialize or work in the 
     field of public health;
       ``(3) to plan, develop, operate, or participate in a 
     program for the training of public health professionals who 
     plan to teach in any program described in paragraph (1); and
       ``(4) to provide financial assistance in the form of 
     traineeships and fellowships to public health professionals 
     who are participants in any program described in paragraph 
     (1) and who plan to teach in the field of public health, 
     including nursing; health administration, management, or 
     policy; preventive medicine; laboratory science; veterinary 
     medicine; or dental medicine.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under this section, an entity shall be--
       ``(1) an accredited health professions school, including an 
     accredited school or program of public health; nursing; 
     health administration, management, or policy; preventive 
     medicine; laboratory science; veterinary medicine; or dental 
     medicine;
       ``(2) a State, local, or tribal health department;
       ``(3) a public or private nonprofit entity; or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(d) Preference.--In awarding grants or contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Training a high or significantly improved percentage 
     of public health professionals who serve in underserved 
     communities.
       ``(2) Training individuals who are from disadvantaged 
     backgrounds (including racial and ethnic minorities 
     underrepresented among public health professionals).
       ``(3) Training individuals in public health specialties 
     experiencing a significant shortage of public health 
     professionals (as determined by the Secretary).
       ``(4) Training a high or significantly improved percentage 
     of public health professionals serving in the Federal 
     Government or a State, local, or tribal government.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.''.

     SEC. 2233. PUBLIC HEALTH TRAINING CENTERS.

       Section 766 (42 U.S.C. 295a) is amended--
       (1) in subsection (b)(1), by striking ``in furtherance of 
     the goals established by the Secretary for the year 2000'' 
     and inserting ``in furtherance of the goals established by 
     the Secretary in the national prevention and wellness 
     strategy under section 3121''; and
       (2) by adding at the end the following:
       ``(d) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.''.

     SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING 
                   GRANT PROGRAM.

       Section 768 (42 U.S.C. 295c) is amended to read as follows:

     ``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING 
                   GRANT PROGRAM.

       ``(a) Grants.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Director of the 
     Centers for Disease Control and Prevention, shall award 
     grants to, or enter into contracts with, eligible entities to 
     provide training to graduate medical residents in preventive 
     medicine specialties.
       ``(b) Eligibility.--To be eligible for a grant or contract 
     under subsection (a), an entity shall be--
       ``(1) an accredited school of public health or school of 
     medicine or osteopathic medicine;
       ``(2) an accredited public or private nonprofit hospital;
       ``(3) a State, local, or tribal health department; or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(c) Use of Funds.--Amounts received under a grant or 
     contract under this section shall be used to--
       ``(1) plan, develop (including the development of 
     curricula), operate, or participate in

[[Page 27352]]

     an accredited residency or internship program in preventive 
     medicine or public health;
       ``(2) defray the costs of practicum experiences, as 
     required in such a program; and
       ``(3) establish, maintain, or improve--
       ``(A) academic administrative units (including departments, 
     divisions, or other appropriate units) in preventive medicine 
     and public health; or
       ``(B) programs that improve clinical teaching in preventive 
     medicine and public health.
       ``(d) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.''.

     SEC. 2235. AUTHORIZATION OF APPROPRIATIONS.

       (a) In General.--Section 799C, as added by section 2216 of 
     this Act, is amended by adding at the end the following:
       ``(b) Public Health Workforce.--For the purpose of carrying 
     out subpart XII of part D of title III and sections 765, 766, 
     and 768, in addition to any other amounts authorized to be 
     appropriated for such purpose, there are authorized to be 
     appropriated, out of any monies in the Public Health 
     Investment Fund, the following:
       ``(1) $51,000,000 for fiscal year 2011.
       ``(2) $54,000,000 for fiscal year 2012.
       ``(3) $57,000,000 for fiscal year 2013.
       ``(4) $59,000,000 for fiscal year 2014.
       ``(5) $62,000,000 for fiscal year 2015.''.
       (b) Existing Authorization of Appropriations.--Subsection 
     (a) of section 770 (42 U.S.C. 295e) is amended by striking 
     ``2002'' and inserting ``2015''.

     Subtitle D--Adapting Workforce to Evolving Health System Needs

           PART 1--HEALTH PROFESSIONS TRAINING FOR DIVERSITY

     SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STUDENTS, LOAN 
                   REPAYMENTS AND FELLOWSHIPS REGARDING FACULTY 
                   POSITIONS, AND EDUCATIONAL ASSISTANCE IN THE 
                   HEALTH PROFESSIONS REGARDING INDIVIDUALS FROM 
                   DISADVANTAGED BACKGROUNDS.

       Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) is 
     amended by striking ``not more than $20,000'' and all that 
     follows through the end of the paragraph and inserting: ``not 
     more than $35,000 (plus, beginning with fiscal year 2012, an 
     amount determined by the Secretary on an annual basis to 
     reflect inflation) of the principal and interest of the 
     educational loans of such individuals.''.

     SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS.

       Subsection (b) of section 821 (42 U.S.C. 296m) is amended--
       (1) in the heading, by striking ``Guidance'' and inserting 
     ``Consultation''; and
       (2) by striking ``shall take into consideration'' and all 
     that follows through ``consult with nursing associations'' 
     and inserting ``shall, as appropriate, consult with nursing 
     associations''.

     SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY 
                   PROGRAMS.

       (a) In General.--Title VII (42 U.S.C. 292 et seq.) is 
     amended by inserting after section 739 the following:

     ``SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL 
                   COMPETENCY PROGRAMS.

       ``The Secretary shall, to the extent practicable, 
     coordinate the activities carried out under this part and 
     section 821 in order to enhance the effectiveness of such 
     activities and avoid duplication of effort.''.
       (b) Report.--Section 736 (42 U.S.C. 293) is amended--
       (1) by redesignating subsection (h) as subsection (i); and
       (2) by inserting after subsection (g) the following:
       ``(h) Report.--The Secretary shall submit to the Congress 
     an annual report on the activities carried out under this 
     section.''.

              PART 2--INTERDISCIPLINARY TRAINING PROGRAMS

     SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY TRAINING FOR 
                   HEALTH PROFESSIONALS.

       Section 741 (42 U.S.C. 293e) is amended--
       (1) in the section heading, by striking ``GRANTS FOR HEALTH 
     PROFESSIONS EDUCATION'' and inserting ``CULTURAL AND 
     LINGUISTIC COMPETENCY TRAINING FOR HEALTH PROFESSIONALS'';
       (2) by redesignating subsection (b) as subsection (h); and
       (3) by striking subsection (a) and inserting the following:
       ``(a) Program.--The Secretary shall establish a cultural 
     and linguistic competency training program for health 
     professionals, including nurse professionals, consisting of 
     awarding grants and contracts under subsection (b).
       ``(b) Cultural and Linguistic Competency Training.--The 
     Secretary shall award grants to, or enter into contracts 
     with, eligible entities--
       ``(1) to test, develop, and evaluate models of cultural and 
     linguistic competency training (including continuing 
     education) for health professionals; and
       ``(2) to implement cultural and linguistic competency 
     training programs for health professionals developed under 
     paragraph (1) or otherwise.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under subsection (b), an entity shall be--
       ``(1) an accredited health professions school or program;
       ``(2) an academic health center;
       ``(3) a public or private nonprofit entity; or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(d) Preference.--In awarding grants and contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Addressing, or partnering with an entity with 
     experience addressing, the cultural and linguistic competency 
     needs of the population to be served through the grant or 
     contract.
       ``(2) Addressing health disparities.
       ``(3) Placing health professionals in regions experiencing 
     significant changes in the cultural and linguistic 
     demographics of populations, including communities along the 
     United States-Mexico border.
       ``(4) Carrying out activities described in subsection (b) 
     with respect to more than one health profession discipline, 
     specialty, or subspecialty.
       ``(e) Consultation.--The Secretary shall carry out this 
     section in consultation with the heads of appropriate health 
     agencies and offices in the Department of Health and Human 
     Services, including the Office of Minority Health and the 
     National Center on Minority Health and Health Disparities.
       ``(f) Definition.--In this section, the term `health 
     disparities' has the meaning given to the term in section 
     3171.
       ``(g) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.''.

     SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

       Part D of title VII (42 U.S.C. 294 et seq.) is amended by 
     adding at the end the following:

     ``SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

       ``(a) Program.--The Secretary shall establish an 
     innovations in interdisciplinary care training program 
     consisting of awarding grants and contracts under subsection 
     (b).
       ``(b) Training Programs.--The Secretary shall award grants 
     to, or enter into contracts with, eligible entities--
       ``(1) to test, develop, and evaluate health professional 
     training programs (including continuing education) designed 
     to promote--
       ``(A) the delivery of health services through 
     interdisciplinary and team-based models, which may include 
     patient-centered medical home models, medication therapy 
     management models, and models integrating physical, mental, 
     or oral health services; and
       ``(B) coordination of the delivery of health care within 
     and across settings, including health care institutions, 
     community-based settings, and the patient's home; and
       ``(2) to implement such training programs developed under 
     paragraph (1) or otherwise.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under subsection (b), an entity shall be--
       ``(1) an accredited health professions school or program;
       ``(2) an academic health center;
       ``(3) a public or private nonprofit entity (including an 
     area health education center or a geriatric education 
     center); or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(d) Preferences.--In awarding grants and contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Training a high or significantly improved percentage 
     of health professionals who serve in underserved communities.
       ``(2) Broad interdisciplinary team-based collaborations.
       ``(3) Addressing health disparities.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the program carried out under this 
     section.
       ``(f) Definitions.--In this section:
       ``(1) The term `health disparities' has the meaning given 
     the term in section 3171.
       ``(2) The term `interdisciplinary' means collaboration 
     across health professions and specialties, which may include 
     public health, nursing, allied health, dietetics or 
     nutrition, and appropriate health specialties.''.

     PART 3--ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND 
                               ASSESSMENT

     SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

       Subpart 1 of part E of title VII (42 U.S.C. 294n et seq.) 
     is amended by adding at the end the following:

     ``SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

       ``(a) Advisory Committee.--The Secretary, acting through 
     the Assistant Secretary for Health, shall establish a 
     permanent advisory committee to be known as the Advisory 
     Committee on Health Workforce Evaluation and Assessment 
     (referred to in this section as the `Advisory Committee') to 
     develop and implement an integrated, coordinated, and 
     strategic national health workforce policy reflective of 
     current and evolving health workforce needs.
       ``(b) Responsibilities.--The Advisory Committee shall--
       ``(1) not later than 1 year after the date of the 
     establishment of the Advisory Committee, submit 
     recommendations to the Secretary on--

[[Page 27353]]

       ``(A) classifications of the health workforce to ensure 
     consistency of data collection on the health workforce; and
       ``(B) based on such classifications, standardized 
     methodologies and procedures to enumerate the health 
     workforce;
       ``(2) not later than 2 years after the date of the 
     establishment of the Advisory Committee, submit 
     recommendations to the Secretary on--
       ``(A) the supply, diversity, and geographic distribution of 
     the health workforce;
       ``(B) the retention and expansion of the health workforce 
     (on a short- and long-term basis) to ensure quality and 
     adequacy of such workforce; and
       ``(C) policies to carry out the recommendations made 
     pursuant to subparagraphs (A) and (B); and
       ``(3) not later than 4 years after the date of the 
     establishment of the Advisory Committee, and every 2 years 
     thereafter, submit updated recommendations to the Secretary 
     under paragraphs (1) and (2).
       ``(c) Role of Agency.--The Secretary shall provide ongoing 
     administrative, research, and technical support for the 
     operations of the Advisory Committee, including coordinating 
     and supporting the dissemination of the recommendations of 
     the Advisory Committee.
       ``(d) Membership.--
       ``(1) Number; appointment.--The Secretary shall appoint 15 
     members to serve on the Advisory Committee.
       ``(2) Terms.--
       ``(A) In general.--The Secretary shall appoint members of 
     the Advisory Committee for a term of 3 years and may 
     reappoint such members, but the Secretary may not appoint any 
     member to serve more than a total of 6 years.
       ``(B) Staggered terms.--Notwithstanding subparagraph (A), 
     of the members first appointed to the Advisory Committee 
     under paragraph (1)--
       ``(i) 5 shall be appointed for a term of 1 year;
       ``(ii) 5 shall be appointed for a term of 2 years; and
       ``(iii) 5 shall be appointed for a term of 3 years.
       ``(3) Qualifications.--Members of the Advisory Committee 
     shall be appointed from among individuals who possess 
     expertise in at least one of the following areas:
       ``(A) Conducting and interpreting health workforce market 
     analysis, including health care labor workforce analysis.
       ``(B) Conducting and interpreting health finance and 
     economics research.
       ``(C) Delivering and administering health care services.
       ``(D) Delivering and administering health workforce 
     education and training.
       ``(4) Representation.--In appointing members of the 
     Advisory Committee, the Secretary shall--
       ``(A) include no less than one representative of each of--
       ``(i) health professionals within the health workforce;
       ``(ii) health care patients and consumers;
       ``(iii) employers;
       ``(iv) labor unions; and
       ``(v) third-party health payors; and
       ``(B) ensure that--
       ``(i) all areas of expertise described in paragraph (3) are 
     represented;
       ``(ii) the members of the Advisory Committee include 
     members who, collectively, have significant experience 
     working with--

       ``(I) populations in urban and federally designated rural 
     and nonmetropolitan areas; and
       ``(II) populations who are underrepresented in the health 
     professions, including underrepresented minority groups; and

       ``(iii) individuals who are directly involved in health 
     professions education or practice do not constitute a 
     majority of the members of the Advisory Committee.
       ``(5) Disclosure and conflicts of interest.--Members of the 
     Advisory Committee shall not be considered employees of the 
     Federal Government by reason of service on the Advisory 
     Committee, except members of the Advisory Committee shall be 
     considered to be special Government employees within the 
     meaning of section 107 of the Ethics in Government Act of 
     1978 (5 U.S.C. App.) and section 208 of title 18, United 
     States Code, for the purposes of disclosure and management of 
     conflicts of interest under those sections.
       ``(6) No pay; receipt of travel expenses.--Members of the 
     Advisory Committee shall not receive any pay for service on 
     the Committee, but may receive travel expenses, including a 
     per diem, in accordance with applicable provisions of 
     subchapter I of chapter 57 of title 5, United States Code.
       ``(e) Consultation.--In carrying out this section, the 
     Secretary shall consult with the Secretary of Education and 
     the Secretary of Labor.
       ``(f) Collaboration.--The Advisory Committee shall 
     collaborate with the advisory bodies at the Health Resources 
     and Services Administration, the National Advisory Council 
     (as authorized in section 337), the Advisory Committee on 
     Training in Primary Care Medicine and Dentistry (as 
     authorized in section 749A), the Advisory Committee on 
     Interdisciplinary, Community-Based Linkages (as authorized in 
     section 756), the Advisory Council on Graduate Medical 
     Education (as authorized in section 762), and the National 
     Advisory Council on Nurse Education and Practice (as 
     authorized in section 851).
       ``(g) FACA.--The Federal Advisory Committee Act (5 U.S.C. 
     App.) except for section 14 of such Act shall apply to the 
     Advisory Committee under this section only to the extent that 
     the provisions of such Act do not conflict with the 
     requirements of this section.
       ``(h) Report.--The Secretary shall submit to the Congress 
     an annual report on the activities of the Advisory Committee.
       ``(i) Definition.--In this section, the term `health 
     workforce' includes all health care providers with direct 
     patient care and support responsibilities, including 
     physicians, nurses, physician assistants, pharmacists, oral 
     health professionals (as defined in section 749(f)(2)), 
     allied health professionals, mental and behavioral health 
     professionals (as defined in section 775(f)(2)), and public 
     health professionals (including veterinarians engaged in 
     public health practice).''.

                  PART 4--HEALTH WORKFORCE ASSESSMENT

     SEC. 2271. HEALTH WORKFORCE ASSESSMENT.

       (a) In General.--Section 761 (42 U.S.C. 294n) is amended--
       (1) by redesignating subsection (c) as subsection (e); and
       (2) by striking subsections (a) and (b) and inserting the 
     following:
       ``(a) In General.--The Secretary shall, based upon the 
     classifications and standardized methodologies and procedures 
     developed by the Advisory Committee on Health Workforce 
     Evaluation and Assessment under section 764(b)--
       ``(1) collect data on the health workforce (as defined in 
     section 764(i)), disaggregated by field, discipline, and 
     specialty, with respect to--
       ``(A) the supply (including retention) of health 
     professionals relative to the demand for such professionals;
       ``(B) the diversity of health professionals (including with 
     respect to race, ethnic background, and sex); and
       ``(C) the geographic distribution of health professionals; 
     and
       ``(2) collect such data on individuals participating in the 
     programs authorized by subtitles A, B, and C and part 1 of 
     subtitle D of title II of division C of the Affordable Health 
     Care for America Act.
       ``(b) Grants and Contracts for Health Workforce Analysis.--
       ``(1) In general.--The Secretary may award grants to, or 
     enter into contracts with, eligible entities to carry out 
     subsection (a).
       ``(2) Eligibility.--To be eligible for a grant or contract 
     under this subsection, an entity shall be--
       ``(A) an accredited health professions school or program;
       ``(B) an academic health center;
       ``(C) a State, local, or tribal government;
       ``(D) a public or private entity; or
       ``(E) a consortium of 2 or more entities described in 
     subparagraphs (A) through (D).
       ``(c) Collaboration and Data Sharing.--The Secretary shall 
     collaborate with Federal departments and agencies, health 
     professions organizations (including health professions 
     education organizations), and professional medical societies 
     for the purpose of carrying out subsection (a).
       ``(d) Report.--The Secretary shall submit to the Congress 
     an annual report on the data collected under subsection 
     (a).''.
       (b) Period Before Completion of National Strategy.--Pending 
     completion of the classifications and standardized 
     methodologies and procedures developed by the Advisory 
     Committee on Health Workforce Evaluation and Assessment under 
     section 764(b) of the Public Health Service Act, as added by 
     section 2261, the Secretary of Health and Human Services, 
     acting through the Administrator of the Health Resources and 
     Services Administration and in consultation with such 
     Advisory Committee, may make a judgment about the 
     classifications, methodologies, and procedures to be used for 
     collection of data under section 761(a) of the Public Health 
     Service Act, as amended by this section.

                PART 5--AUTHORIZATION OF APPROPRIATIONS

     SEC. 2281. AUTHORIZATION OF APPROPRIATIONS.

       (a) In General.--Section 799C, as added and amended, is 
     further amended by adding at the end the following:
       ``(c) Health Professions Training for Diversity.--For the 
     purpose of carrying out sections 736, 737, 738, 739, and 
     739A, in addition to any other amounts authorized to be 
     appropriated for such purpose, there are authorized to be 
     appropriated, out of any monies in the Public Health 
     Investment Fund, the following:
       ``(1) $90,000,000 for fiscal year 2011.
       ``(2) $97,000,000 for fiscal year 2012.
       ``(3) $100,000,000 for fiscal year 2013.
       ``(4) $104,000,000 for fiscal year 2014.
       ``(5) $110,000,000 for fiscal year 2015.
       ``(d) Interdisciplinary Training Programs, Advisory 
     Committee on Health Workforce Evaluation and Assessment, and 
     Health Workforce Assessment.--For the purpose of carrying out 
     sections 741, 759, 761, and 764, in addition to any other 
     amounts authorized to be appropriated for such purpose, there 
     are authorized to be appropriated, out of any monies in the 
     Public Health Investment Fund, the following:

[[Page 27354]]

       ``(1) $87,000,000 for fiscal year 2011.
       ``(2) $97,000,000 for fiscal year 2012.
       ``(3) $103,000,000 for fiscal year 2013.
       ``(4) $105,000,000 for fiscal year 2014.
       ``(5) $113,000,000 for fiscal year 2015.''.
       (b) Existing Authorizations of Appropriations.--
       (1) Section 736.--Paragraph (1) of section 736(i) (42 
     U.S.C. 293(h)), as redesignated, is amended by striking 
     ``2002'' and inserting ``2015''.
       (2) Sections 737, 738, and 739.--Subsections (a), (b), and 
     (c) of section 740 are amended by striking ``2002'' each 
     place it appears and inserting ``2015''.
       (3) Section 741.--Subsection (h), as so redesignated, of 
     section 741 is amended--
       (A) by striking ``and'' after ``fiscal year 2003,''; and
       (B) by inserting ``, and such sums as may be necessary for 
     each subsequent fiscal year through the end of fiscal year 
     2015'' before the period at the end.
       (4) Section 761.--Subsection (e)(1), as so redesignated, of 
     section 761 is amended by striking ``2002'' and inserting 
     ``2015''.

                   TITLE III--PREVENTION AND WELLNESS

     SEC. 2301. PREVENTION AND WELLNESS.

       (a) In General.--The Public Health Service Act (42 U.S.C. 
     201 et seq.) is amended by inserting after title XXX the 
     following:

                 ``TITLE XXXI--PREVENTION AND WELLNESS

              ``Subtitle A--Prevention and Wellness Trust

     ``SEC. 3111. PREVENTION AND WELLNESS TRUST.

       (a) ``Deposits Into Trust.--There is established a 
     Prevention and Wellness Trust. There are authorized to be 
     appropriated to the Trust, out of any monies in the Public 
     Health Investment Fund--
       ``(1) for fiscal year 2011, $2,400,000,000;
       ``(2) for fiscal year 2012, $2,845,000,000;
       ``(3) for fiscal year 2013, $3,100,000,000;
       ``(4) for fiscal year 2014, $3,455,000,000; and
       ``(5) for fiscal year 2015, $3,600,000,000.
       ``(b) Availability of Funds.--Amounts in the Prevention and 
     Wellness Trust shall be available, as provided in advance in 
     appropriation Acts, for carrying out this title.
       ``(c) Allocation.--Of the amounts authorized to be 
     appropriated in subsection (a), there are authorized to be 
     appropriated--
       ``(1) for carrying out subtitle C (Prevention Task Forces), 
     $30,000,000 for each of fiscal years 2011 through 2015;
       ``(2) for carrying out subtitle D (Prevention and Wellness 
     Research)--
       ``(A) for fiscal year 2011, $155,000,000;
       ``(B) for fiscal year 2012, $205,000,000;
       ``(C) for fiscal year 2013, $255,000,000;
       ``(D) for fiscal year 2014, $305,000,000; and
       ``(E) for fiscal year 2015, $355,000,000;
       ``(3) for carrying out subtitle E (Delivery of Community 
     Preventive and Wellness Services)--
       ``(A) for fiscal year 2011, $1,065,000,000;
       ``(B) for fiscal year 2012, $1,260,000,000;
       ``(C) for fiscal year 2013, $1,365,000,000;
       ``(D) for fiscal year 2014, $1,570,000,000; and
       ``(E) for fiscal year 2015, $1,600,000,000;
       ``(4) for carrying out section 3161 (Core Public Health 
     Infrastructure for State, Local, and Tribal Health 
     Departments)--
       ``(A) for fiscal year 2011, $800,000,000;
       ``(B) for fiscal year 2012, $1,000,000,000;
       ``(C) for fiscal year 2013, $1,100,000,000;
       ``(D) for fiscal year 2014, $1,200,000,000; and
       ``(E) for fiscal year 2015, $1,265,000,000; and
       ``(5) for carrying out section 3162 (Core Public Health 
     Infrastructure and Activities for CDC), $350,000,000 for each 
     of fiscal years 2011 through 2015.

        ``Subtitle B--National Prevention and Wellness Strategy

     ``SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY.

       ``(a) In General.--The Secretary shall submit to the 
     Congress within one year after the date of the enactment of 
     this section, and at least every 2 years thereafter, a 
     national strategy that is designed to improve the Nation's 
     health through evidence-based clinical and community 
     prevention and wellness activities (in this section referred 
     to as `prevention and wellness activities'), including core 
     public health infrastructure improvement activities.
       ``(b) Contents.--The strategy under subsection (a) shall 
     include each of the following:
       ``(1) Identification of specific national goals and 
     objectives in prevention and wellness activities that take 
     into account appropriate public health measures and 
     standards, including departmental measures and standards 
     (including Healthy People and National Public Health 
     Performance Standards).
       ``(2) Establishment of national priorities for prevention 
     and wellness, taking into account unmet prevention and 
     wellness needs.
       ``(3) Establishment of national priorities for research on 
     prevention and wellness, taking into account unanswered 
     research questions on prevention and wellness.
       ``(4) Identification of health disparities in prevention 
     and wellness.
       ``(5) Review of prevention payment incentives, the 
     prevention workforce, and prevention delivery system 
     capacity.
       ``(6) A plan for addressing and implementing paragraphs (1) 
     through (5).
       ``(c) Consultation.--In developing or revising the strategy 
     under subsection (a), the Secretary shall consult with the 
     following:
       ``(1) The heads of appropriate health agencies and offices 
     in the Department, including the Office of the Surgeon 
     General of the Public Health Service, the Office of Minority 
     Health, the Office on Women's Health, and the Substance Abuse 
     and Mental Health Services Administration.
       ``(2) As appropriate, the heads of other Federal 
     departments and agencies whose programs have a significant 
     impact upon health (as determined by the Secretary).
       ``(3) As appropriate, nonprofit and for-profit entities.
       ``(4) The Association of State and Territorial Health 
     Officials and the National Association of County and City 
     Health Officials.
       ``(5) The Task Force on Community Preventive Services and 
     the Task Force on Clinical Preventive Services.

                  ``Subtitle C--Prevention Task Forces

     ``SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERVICES.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Agency for Healthcare Research and Quality, 
     shall establish a permanent task force to be known as the 
     Task Force on Clinical Preventive Services (in this section 
     referred to as the `Task Force').
       ``(b) Responsibilities.--The Task Force shall--
       ``(1) identify clinical preventive services for review;
       ``(2) review the scientific evidence related to the 
     benefits, effectiveness, appropriateness, and costs of 
     clinical preventive services identified under paragraph (1) 
     for the purpose of developing, updating, publishing, and 
     disseminating evidence-based recommendations on the use of 
     such services;
       ``(3) as appropriate, take into account health disparities 
     in developing, updating, publishing, and disseminating 
     evidence-based recommendations on the use of such services;
       ``(4) identify gaps in clinical preventive services 
     research and evaluation and recommend priority areas for such 
     research and evaluation;
       ``(5) pursuant to section 3143(c), determine whether 
     subsidies and rewards meet the Task Force's standards for a 
     grade of A or B;
       ``(6) as appropriate, consult with the clinical prevention 
     stakeholders board in accordance with subsection (f);
       ``(7) consult with the Task Force on Community Preventive 
     Services established under section 3132; and
       ``(8) as appropriate, in carrying out this section, 
     consider the national strategy under section 3121.
       ``(c) Role of Agency.--The Secretary shall provide ongoing 
     administrative, research, and technical support for the 
     operations of the Task Force, including coordinating and 
     supporting the dissemination of the recommendations of the 
     Task Force.
       ``(d) Membership.--
       ``(1) Number; appointment.--The Task Force shall be 
     composed of 30 members, appointed by the Secretary.
       ``(2) Terms.--
       ``(A) In general.--The Secretary shall appoint members of 
     the Task Force for a term of 6 years and may reappoint such 
     members, but the Secretary may not appoint any member to 
     serve more than a total of 12 years.
       ``(B) Staggered terms.--Notwithstanding subparagraph (A), 
     of the members first appointed to serve on the Task Force 
     after the enactment of this title--
       ``(i) 10 shall be appointed for a term of 2 years;
       ``(ii) 10 shall be appointed for a term of 4 years; and
       ``(iii) 10 shall be appointed for a term of 6 years.
       ``(3) Qualifications.--Members of the Task Force shall be 
     appointed from among individuals who possess expertise in at 
     least one of the following areas:
       ``(A) Health promotion and disease prevention.
       ``(B) Evaluation of research and systematic evidence 
     reviews.
       ``(C) Application of systematic evidence reviews to 
     clinical decisionmaking or health policy.
       ``(D) Clinical primary care in child and adolescent health.
       ``(E) Clinical primary care in adult health, including 
     women's health.
       ``(F) Clinical primary care in geriatrics.
       ``(G) Clinical counseling and behavioral services for 
     primary care patients.
       ``(4) Representation.--In appointing members of the Task 
     Force, the Secretary shall ensure that--
       ``(A) all areas of expertise described in paragraph (3) are 
     represented; and
       ``(B) the members of the Task Force include individuals 
     with expertise in health disparities.
       ``(e) Subgroups.--As appropriate to maximize efficiency, 
     the Task Force may delegate authority for conducting reviews 
     and making recommendations to subgroups consisting of Task 
     Force members, subject to final approval by the Task Force.
       ``(f) Clinical Prevention Stakeholders Board.--
       ``(1) In general.--The Task Force shall convene a clinical 
     prevention stakeholders

[[Page 27355]]

     board composed of representatives of appropriate public and 
     private entities with an interest in clinical preventive 
     services to advise the Task Force on developing, updating, 
     publishing, and disseminating evidence-based recommendations 
     on the use of clinical preventive services.
       ``(2) Membership.--The members of the clinical prevention 
     stakeholders board shall include representatives of the 
     following:
       ``(A) Health care consumers and patient groups.
       ``(B) Providers of clinical preventive services, including 
     community-based providers.
       ``(C) Federal departments and agencies, including--
       ``(i) appropriate health agencies and offices in the 
     Department, including the Office of the Surgeon General of 
     the Public Health Service, the Office of Minority Health, the 
     National Center on Minority Health and Health Disparities, 
     and the Office on Women's Health; and
       ``(ii) as appropriate, other Federal departments and 
     agencies whose programs have a significant impact upon health 
     (as determined by the Secretary).
       ``(D) Private health care payors.
       ``(3) Responsibilities.--In accordance with subsection 
     (b)(6), the clinical prevention stakeholders board shall--
       ``(A) recommend clinical preventive services for review by 
     the Task Force;
       ``(B) suggest scientific evidence for consideration by the 
     Task Force related to reviews undertaken by the Task Force;
       ``(C) provide feedback regarding draft recommendations by 
     the Task Force; and
       ``(D) assist with efforts regarding dissemination of 
     recommendations by the Director of the Agency for Healthcare 
     Research and Quality.
       ``(g) Disclosure and Conflicts of Interest.--Members of the 
     Task Force or the clinical prevention stakeholders board 
     shall not be considered employees of the Federal Government 
     by reason of service on the Task Force or the clinical 
     prevention stakeholders board, except members of the Task 
     Force or the clinical prevention stakeholders board shall be 
     considered to be special Government employees within the 
     meaning of section 107 of the Ethics in Government Act of 
     1978 (5 U.S.C. App.) and section 208 of title 18, United 
     States Code, for the purposes of disclosure and management of 
     conflicts of interest under those sections.
       ``(h) No Pay; Receipt of Travel Expenses.--Members of the 
     Task Force or the clinical prevention stakeholders board 
     shall not receive any pay for service on the Task Force, but 
     may receive travel expenses, including a per diem, in 
     accordance with applicable provisions of subchapter I of 
     chapter 57 of title 5, United States Code.
       ``(i) Application of FACA.--The Federal Advisory Committee 
     Act (5 U.S.C. App.) except for section 14 of such Act shall 
     apply to the Task Force to the extent that the provisions of 
     such Act do not conflict with the provisions of this title.
       ``(j) Report.--The Secretary shall submit to the Congress 
     an annual report on the Task Force, including with respect to 
     gaps identified and recommendations made under subsection 
     (b)(4).

     ``SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a permanent task force to be known as the 
     Task Force on Community Preventive Services (in this section 
     referred to as the `Task Force').
       ``(b) Responsibilities.--The Task Force shall--
       ``(1) identify community preventive services for review;
       ``(2) review the scientific evidence related to the 
     benefits, effectiveness, appropriateness, and costs of 
     community preventive services identified under paragraph (1) 
     for the purpose of developing, updating, publishing, and 
     disseminating evidence-based recommendations on the use of 
     such services;
       ``(3) as appropriate, take into account health disparities 
     in developing, updating, publishing, and disseminating 
     evidence-based recommendations on the use of such services;
       ``(4) identify gaps in community preventive services 
     research and evaluation and recommend priority areas for such 
     research and evaluation;
       ``(5) pursuant to section 3143(d), determine whether 
     subsidies and rewards are effective;
       ``(6) as appropriate, consult with the community prevention 
     stakeholders board in accordance with subsection (f);
       ``(7) consult with the Task Force on Clinical Preventive 
     Services established under section 3131; and
       ``(8) as appropriate, in carrying out this section, 
     consider the national strategy under section 3121.
       ``(c) Role of Agency.--The Secretary shall provide ongoing 
     administrative, research, and technical support for the 
     operations of the Task Force, including coordinating and 
     supporting the dissemination of the recommendations of the 
     Task Force.
       ``(d) Membership.--
       ``(1) Number; appointment.--The Task Force shall be 
     composed of 30 members, appointed by the Secretary.
       ``(2) Terms.--
       ``(A) In general.--The Secretary shall appoint members of 
     the Task Force for a term of 6 years and may reappoint such 
     members, but the Secretary may not appoint any member to 
     serve more than a total of 12 years.
       ``(B) Staggered terms.--Notwithstanding subparagraph (A), 
     of the members first appointed to serve on the Task Force 
     after the enactment of this section--
       ``(i) 10 shall be appointed for a term of 2 years;
       ``(ii) 10 shall be appointed for a term of 4 years; and
       ``(iii) 10 shall be appointed for a term of 6 years.
       ``(3) Qualifications.--Members of the Task Force shall be 
     appointed from among individuals who possess expertise in at 
     least one of the following areas:
       ``(A) Public health.
       ``(B) Evaluation of research and systematic evidence 
     reviews.
       ``(C) Disciplines relevant to community preventive 
     services, including health promotion; disease prevention; 
     chronic disease; worksite health; school-site health; 
     qualitative and quantitative analysis; and health economics, 
     policy, law, and statistics.
       ``(4) Representation.--In appointing members of the Task 
     Force, the Secretary--
       ``(A) shall ensure that all areas of expertise described in 
     paragraph (3) are represented;
       ``(B) shall ensure that such members include sufficient 
     representatives of each of--
       ``(i) State health officers;
       ``(ii) local health officers;
       ``(iii) health care practitioners; and
       ``(iv) public health practitioners; and
       ``(C) shall appoint individuals who have expertise in 
     health disparities.
       ``(e) Subgroups.--As appropriate to maximize efficiency, 
     the Task Force may delegate authority for conducting reviews 
     and making recommendations to subgroups consisting of Task 
     Force members, subject to final approval by the Task Force.
       ``(f) Community Prevention Stakeholders Board.--
       ``(1) In general.--The Task Force shall convene a community 
     prevention stakeholders board composed of representatives of 
     appropriate public and private entities with an interest in 
     community preventive services to advise the Task Force on 
     developing, updating, publishing, and disseminating evidence-
     based recommendations on the use of community preventive 
     services.
       ``(2) Membership.--The members of the community prevention 
     stakeholders board shall include representatives of the 
     following:
       ``(A) Health care consumers and patient groups.
       ``(B) Providers of community preventive services, including 
     community-based providers.
       ``(C) Federal departments and agencies, including--
       ``(i) appropriate health agencies and offices in the 
     Department, including the Office of the Surgeon General of 
     the Public Health Service, the Office of Minority Health, the 
     National Center on Minority Health and Health Disparities, 
     and the Office on Women's Health; and
       ``(ii) as appropriate, other Federal departments and 
     agencies whose programs have a significant impact upon health 
     (as determined by the Secretary).
       ``(D) Private health care payors.
       ``(3) Responsibilities.--In accordance with subsection 
     (b)(6), the community prevention stakeholders board shall--
       ``(A) recommend community preventive services for review by 
     the Task Force;
       ``(B) suggest scientific evidence for consideration by the 
     Task Force related to reviews undertaken by the Task Force;
       ``(C) provide feedback regarding draft recommendations by 
     the Task Force; and
       ``(D) assist with efforts regarding dissemination of 
     recommendations by the Director of the Centers for Disease 
     Control and Prevention.
       ``(g) Disclosure and Conflicts of Interest.--Members of the 
     Task Force or the community prevention stakeholders board 
     shall not be considered employees of the Federal Government 
     by reason of service on the Task Force or the community 
     prevention stakeholders board, except members of the Task 
     Force or the community prevention stakeholders board shall be 
     considered to be special Government employees within the 
     meaning of section 107 of the Ethics in Government Act of 
     1978 (5 U.S.C. App.) and section 208 of title 18, United 
     States Code, for the purposes of disclosure and management of 
     conflicts of interest under those sections.
       ``(h) No Pay; Receipt of Travel Expenses.--Members of the 
     Task Force or the community prevention stakeholders board 
     shall not receive any pay for service on the Task Force, but 
     may receive travel expenses, including a per diem, in 
     accordance with applicable provisions of subchapter I of 
     chapter 57 of title 5, United States Code.
       ``(i) Application of FACA.--The Federal Advisory Committee 
     Act (5 U.S.C. App.) except for section 14 of such Act shall 
     apply to the Task Force to the extent that the provisions of 
     such Act do not conflict with the provisions of this title.
       ``(j) Report.--The Secretary shall submit to the Congress 
     an annual report on the Task

[[Page 27356]]

     Force, including with respect to gaps identified and 
     recommendations made under subsection (b)(4).

             ``Subtitle D--Prevention and Wellness Research

     ``SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIVITY 
                   COORDINATION.

       ``In conducting or supporting research on prevention and 
     wellness, the Director of the Centers for Disease Control and 
     Prevention, the Director of the National Institutes of 
     Health, and the heads of other agencies within the Department 
     of Health and Human Services conducting or supporting such 
     research, shall take into consideration the national strategy 
     under section 3121 and the recommendations of the Task Force 
     on Clinical Preventive Services under section 3131 and the 
     Task Force on Community Preventive Services under section 
     3132.

     ``SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RESEARCH 
                   GRANTS.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall conduct, or award grants to eligible entities to 
     conduct, research in priority areas identified by the 
     Secretary in the national strategy under section 3121 or by 
     the Task Force on Community Preventive Services as required 
     by section 3132.
       ``(b) Eligibility.--To be eligible for a grant under this 
     section, an entity shall be--
       ``(1) a State, local, or tribal department of health;
       ``(2) a public or private nonprofit entity; or
       ``(3) a consortium of 2 or more entities described in 
     paragraphs (1) and (2).
       ``(c) Report.--The Secretary shall submit to the Congress 
     an annual report on the program of research under this 
     section.

     ``SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO ENCOURAGE 
                   WELLNESS AND HEALTHY BEHAVIORS.

       ``(a) Research and Demonstration Projects.--
       ``(1) In general.--The Secretary shall conduct, or award 
     grants to public or nonprofit private entities to conduct, 
     research and demonstration projects on the use of financial 
     and in-kind subsidies and rewards to encourage individuals 
     and communities to promote wellness, adopt healthy behaviors, 
     and use evidence-based preventive health services.
       ``(2) Focus.--Research and demonstration projects under 
     paragraph (1) shall focus on--
       ``(A) tobacco use, obesity, and other prevention and 
     wellness priorities identified by the Secretary in the 
     national strategy under section 3121;
       ``(B) the initiation, maintenance, and long-term 
     sustainability of wellness promotion; adoption of healthy 
     behaviors; and use of evidence-based preventive health 
     services; and
       ``(C) populations at high risk of preventable diseases and 
     conditions.
       ``(b) Findings; Report.--
       ``(1) Submission of findings.--The Secretary shall submit 
     the findings of research and demonstration projects under 
     subsection (a) to--
       ``(A) the Task Force on Clinical Preventive Services 
     established under section 3131 or the Task Force on Community 
     Preventive Services established under section 3132, as 
     appropriate; and
       ``(B) the Health Benefits Advisory Committee established by 
     section 223 of the Affordable Health Care for America Act.
       ``(2) Report to congress.--Not later than 18 months after 
     the initiation of research and demonstration projects under 
     subsection (a), the Secretary shall submit a report to the 
     Congress on the progress of such research and projects, 
     including any preliminary findings.
       ``(c) Inclusion in Essential Benefits Package.--If, on the 
     basis of the findings of research and demonstration projects 
     under subsection (a) or other sources consistent with section 
     3131, the Task Force on Clinical Preventive Services 
     determines that a subsidy or reward meets the Task Force's 
     standards for a grade A or B, the Secretary shall ensure that 
     the subsidy or reward is included in the essential benefits 
     package under section 222.
       ``(d) Inclusion as Allowable Use of Community Prevention 
     and Wellness Services Grants.--If, on the basis of the 
     findings of research and demonstration projects under 
     subsection (a) or other sources consistent with section 3132, 
     the Task Force on Community Preventive Services determines 
     that a subsidy or reward is effective, the Secretary shall 
     ensure that the subsidy or reward becomes an allowable use of 
     grant funds under section 3151.
       ``(e) Nondiscrimination; No Tie to Premium or Cost 
     Sharing.--In carrying out this section, the Secretary shall 
     ensure that any subsidy or reward--
       ``(1) does not have a discriminatory effect on the basis of 
     any personal characteristic extraneous to the provision of 
     high-quality health care or related services; and
       ``(2) is not tied to the premium or cost sharing of an 
     individual under any qualified health benefits plan (as 
     defined in section 100(c)).

  ``Subtitle E--Delivery of Community Prevention and Wellness Services

     ``SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES 
                   GRANTS.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall establish a program for the delivery of community 
     prevention and wellness services consisting of awarding 
     grants to eligible entities--
       ``(1) to provide evidence-based, community prevention and 
     wellness services in priority areas identified by the 
     Secretary in the national strategy under section 3121; or
       ``(2) to plan such services.
       ``(b) Eligibility.--
       ``(1) Definition.--To be eligible for a grant under this 
     section, an entity shall be--
       ``(A) a State, local, or tribal department of health;
       ``(B) a public or private entity; or
       ``(C) a consortium that--
       ``(i) consists of 2 or more entities described in 
     subparagraph (A) or (B); and
       ``(ii) may be a community partnership representing a Health 
     Empowerment Zone.
       ``(2) Health empowerment zone.--In this subsection, the 
     term `Health Empowerment Zone' means an area--
       ``(A) in which multiple community prevention and wellness 
     services are implemented in order to address one or more 
     health disparities, including those identified by the 
     Secretary in the national strategy under section 3121; and
       ``(B) which is represented by a community partnership that 
     demonstrates community support and coordination with State, 
     local, or tribal health departments and includes--
       ``(i) a broad cross section of stakeholders;
       ``(ii) residents of the community; and
       ``(iii) representatives of entities that have a history of 
     working within and serving the community.
       ``(c) Preferences.--In awarding grants under this section, 
     the Secretary shall give preference to entities that--
       ``(1) will address one or more goals or objectives 
     identified by the Secretary in the national strategy under 
     section 3121;
       ``(2) will address significant health disparities, 
     including those identified by the Secretary in the national 
     strategy under section 3121;
       ``(3) will address unmet community prevention and wellness 
     needs and avoid duplication of effort;
       ``(4) have been demonstrated to be effective in communities 
     comparable to the proposed target community;
       ``(5) will contribute to the evidence base for community 
     prevention and wellness services;
       ``(6) demonstrate that the community prevention and 
     wellness services to be funded will be sustainable; and
       ``(7) demonstrate coordination or collaboration across 
     governmental and nongovernmental partners.
       ``(d) Health Disparities.--Of the funds awarded under this 
     section for a fiscal year, the Secretary shall award not less 
     than 50 percent for planning or implementing community 
     prevention and wellness services whose primary purpose is to 
     achieve a measurable reduction in one or more health 
     disparities, including those identified by the Secretary in 
     the national strategy under section 3121.
       ``(e) Emphasis on Recommended Services.--For fiscal year 
     2014 and subsequent fiscal years, the Secretary shall award 
     grants under this section only for planning or implementing 
     services recommended by the Task Force on Community 
     Preventive Services under section 3132 or deemed effective 
     based on a review of comparable rigor (as determined by the 
     Director of the Centers for Disease Control and Prevention).
       ``(f) Prohibited Uses of Funds.--An entity that receives a 
     grant under this section may not use funds provided through 
     the grant--
       ``(1) to build or acquire real property or for 
     construction; or
       ``(2) for services or planning to the extent that payment 
     has been made, or can reasonably be expected to be made--
       ``(A) under any insurance policy;
       ``(B) under any Federal or State health benefits program 
     (including titles XIX and XXI of the Social Security Act); or
       ``(C) by an entity which provides health services on a 
     prepaid basis.
       ``(g) Report.--The Secretary shall submit to the Congress 
     an annual report on the program of grants awarded under this 
     section.
       ``(h) Definitions.--In this section, the term `evidence-
     based' means that methodologically sound research has 
     demonstrated a beneficial health effect, in the judgment of 
     the Director of the Centers for Disease Control and 
     Prevention.

            ``Subtitle F--Core Public Health Infrastructure

     ``SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR STATE, 
                   LOCAL, AND TRIBAL HEALTH DEPARTMENTS.

       ``(a) Program.--The Secretary, acting through the Director 
     of the Centers for Disease Control and Prevention, shall 
     establish a core public health infrastructure program 
     consisting of awarding grants under subsection (b).
       ``(b) Grants.--
       ``(1) Award.--For the purpose of addressing core public 
     health infrastructure needs, the Secretary--
       ``(A) shall award a grant to each State health department; 
     and
       ``(B) may award grants on a competitive basis to State, 
     local, or tribal health departments.

[[Page 27357]]

       ``(2) Allocation.--Of the total amount of funds awarded as 
     grants under this subsection for a fiscal year--
       ``(A) not less than 50 percent shall be for grants to State 
     health departments under paragraph (1)(A); and
       ``(B) not less than 30 percent shall be for grants to 
     State, local, or tribal health departments under paragraph 
     (1)(B).
       ``(c) Use of Funds.--The Secretary may award a grant to an 
     entity under subsection (b)(1) only if the entity agrees to 
     use the grant to address core public health infrastructure 
     needs, including those identified in the accreditation 
     process under subsection (g).
       ``(d) Formula Grants to State Health Departments.--In 
     making grants under subsection (b)(1)(A), the Secretary shall 
     award funds to each State health department in accordance 
     with--
       ``(1) a formula based on population size; burden of 
     preventable disease and disability; and core public health 
     infrastructure gaps, including those identified in the 
     accreditation process under subsection (g); and
       ``(2) application requirements established by the 
     Secretary, including a requirement that the State submit a 
     plan that demonstrates to the satisfaction of the Secretary 
     that the State's health department will--
       ``(A) address its highest priority core public health 
     infrastructure needs; and
       ``(B) as appropriate, allocate funds to local health 
     departments within the State.
       ``(e) Competitive Grants to State, Local, and Tribal Health 
     Departments.--In making grants under subsection (b)(1)(B), 
     the Secretary shall give priority to applicants demonstrating 
     core public health infrastructure needs identified in the 
     accreditation process under subsection (g).
       ``(f) Maintenance of Effort.--The Secretary may award a 
     grant to an entity under subsection (b) only if the entity 
     demonstrates to the satisfaction of the Secretary that--
       ``(1) funds received through the grant will be expended 
     only to supplement, and not supplant, non-Federal and Federal 
     funds otherwise available to the entity for the purpose of 
     addressing core public health infrastructure needs; and
       ``(2) with respect to activities for which the grant is 
     awarded, the entity will maintain expenditures of non-Federal 
     amounts for such activities at a level not less than the 
     level of such expenditures maintained by the entity for the 
     fiscal year preceding the fiscal year for which the entity 
     receives the grant.
       ``(g) Establishment of a Public Health Accreditation 
     Program.--
       ``(1) In general.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall--
       ``(A) develop, and periodically review and update, 
     standards for voluntary accreditation of State, local, or 
     tribal health departments and public health laboratories for 
     the purpose of advancing the quality and performance of such 
     departments and laboratories; and
       ``(B) implement a program to accredit such health 
     departments and laboratories in accordance with such 
     standards.
       ``(2) Cooperative agreement.--The Secretary may enter into 
     a cooperative agreement with a private nonprofit entity to 
     carry out paragraph (1).
       ``(h) Report.--The Secretary shall submit to the Congress 
     an annual report on progress being made to accredit entities 
     under subsection (g), including--
       ``(1) a strategy, including goals and objectives, for 
     accrediting entities under subsection (g) and achieving the 
     purpose described in subsection (g)(1); and
       ``(2) identification of gaps in research related to core 
     public health infrastructure and recommendations of priority 
     areas for such research.

     ``SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND ACTIVITIES 
                   FOR CDC.

       ``(a) In General.--The Secretary, acting through the 
     Director of the Centers for Disease Control and Prevention, 
     shall expand and improve the core public health 
     infrastructure and activities of the Centers for Disease 
     Control and Prevention to address unmet and emerging public 
     health needs.
       ``(b) Report.--The Secretary shall submit to the Congress 
     an annual report on the activities funded through this 
     section.

                    ``Subtitle G--General Provisions

     ``SEC. 3171. DEFINITIONS.

       ``In this title:
       ``(1) The term `core public health infrastructure' includes 
     workforce capacity and competency; laboratory systems; health 
     information, health information systems, and health 
     information analysis; communications; financing; other 
     relevant components of organizational capacity; and other 
     related activities.
       ``(2) The terms `Department' and `departmental' refer to 
     the Department of Health and Human Services.
       ``(3) The term `health disparities' includes health and 
     health care disparities and means population-specific 
     differences in the presence of disease, health outcomes, or 
     access to health care. For purposes of the preceding 
     sentence, a population may be delineated by race, ethnicity, 
     primary language, sex, sexual orientation, gender identity, 
     disability, socioeconomic status, or rural, urban, or other 
     geographic setting, and any other population or subpopulation 
     determined by the Secretary to experience significant gaps in 
     disease, health outcomes, or access to health care.
       ``(4) The term `tribal' refers to an Indian tribe, a Tribal 
     organization, or an Urban Indian organization, as such terms 
     are defined in section 4 of the Indian Health Care 
     Improvement Act.''.
       (b) Transition Provisions Applicable to Task Forces.--
       (1) Functions, personnel, assets, liabilities, and 
     administrative actions.--All functions, personnel, assets, 
     and liabilities of, and administrative actions applicable to, 
     the Preventive Services Task Force convened under section 
     915(a) of the Public Health Service Act and the Task Force on 
     Community Preventive Services (as such section and Task 
     Forces were in existence on the day before the date of the 
     enactment of this Act) shall be transferred to the Task Force 
     on Clinical Preventive Services and the Task Force on 
     Community Preventive Services, respectively, established 
     under sections 3131 and 3132 of the Public Health Service 
     Act, as added by subsection (a).
       (2) Recommendations.--All recommendations of the Preventive 
     Services Task Force and the Task Force on Community 
     Preventive Services, as in existence on the day before the 
     date of the enactment of this Act, shall be considered to be 
     recommendations of the Task Force on Clinical Preventive 
     Services and the Task Force on Community Preventive Services, 
     respectively, established under sections 3131 and 3132 of the 
     Public Health Service Act, as added by subsection (a).
       (3) Members already serving.--
       (A) Initial members.--The Secretary of Health and Human 
     Services may select those individuals already serving on the 
     Preventive Services Task Force and the Task Force on 
     Community Preventive Services, as in existence on the day 
     before the date of the enactment of this Act, to be among the 
     first members appointed to the Task Force on Clinical 
     Preventive Services and the Task Force on Community 
     Preventive Services, respectively, under sections 3131 and 
     3132 of the Public Health Service Act, as added by subsection 
     (a).
       (B) Calculation of total service.--In calculating the total 
     years of service of a member of a task force for purposes of 
     section 3131(d)(2)(A) or 3132(d)(2)(A) of the Public Health 
     Service Act, as added by subsection (a), the Secretary of 
     Health and Human Services shall not include any period of 
     service by the member on the Preventive Services Task Force 
     or the Task Force on Community Preventive Services, 
     respectively, as in existence on the day before the date of 
     the enactment of this Act.
       (c) Period Before Completion of National Strategy.--Pending 
     completion of the national strategy under section 3121 of the 
     Public Health Service Act, as added by subsection (a), the 
     Secretary of Health and Human Services, acting through the 
     relevant agency head, may make a judgment about how the 
     strategy will address an issue and rely on such judgment in 
     carrying out any provision of subtitle C, D, E, or F of title 
     XXXI of such Act, as added by subsection (a), that requires 
     the Secretary--
       (1) to take into consideration such strategy;
       (2) to conduct or support research or provide services in 
     priority areas identified in such strategy; or
       (3) to take any other action in reliance on such strategy.
       (d) Conforming Amendments.--
       (1) Paragraph (61) of section 3(b) of the Indian Health 
     Care Improvement Act (25 U.S.C. 1602) is amended by striking 
     ``United States Preventive Services Task Force'' and 
     inserting ``Task Force on Clinical Preventive Services''.
       (2) Section 126 of the Medicare, Medicaid, and SCHIP 
     Benefits Improvement and Protection Act of 2000 (Appendix F 
     of Public Law 106-554) is amended by striking ``United States 
     Preventive Services Task Force'' each place it appears and 
     inserting ``Task Force on Clinical Preventive Services''.
       (3) Paragraph (7) of section 317D(a) of the Public Health 
     Service Act (42 U.S.C. 247b-5(a)) is amended by striking 
     ``United States Preventive Services Task Force'' and 
     inserting ``Task Force on Clinical Preventive Services''.
       (4) Section 915 of the Public Health Service Act (42 U.S.C. 
     299b-4) is amended by striking subsection (a).
       (5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and 
     (ddd)(1)(B) of section 1861 of the Social Security Act (42 
     U.S.C. 1395x) are amended by striking ``United States 
     Preventive Services Task Force'' each place it appears and 
     inserting ``Task Force on Clinical Preventive Services''.

                   TITLE IV--QUALITY AND SURVEILLANCE

     SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY 
                   OF HEALTH CARE.

       (a) In General.--Title IX of the Public Health Service Act 
     (42 U.S.C. 299 et seq.) is amended--
       (1) by redesignating part D as part E;
       (2) by redesignating sections 931 through 938 as sections 
     941 through 948, respectively;
       (3) in section 948(1), as redesignated, by striking ``931'' 
     and inserting ``941''; and

[[Page 27358]]

       (4) by inserting after part C the following:

 ``PART D--IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH 
                                  CARE

     ``SEC. 931. CENTER FOR QUALITY IMPROVEMENT.

       ``(a) In General.--There is established the Center for 
     Quality Improvement (referred to in this part as the 
     `Center'), to be headed by the Director.
       ``(b) Prioritization.--
       ``(1) In general.--The Director shall prioritize areas for 
     the identification, development, evaluation, and 
     implementation of best practices (including innovative 
     methodologies and strategies) for quality improvement 
     activities in the delivery of health care services (in this 
     section referred to as `best practices').
       ``(2) Considerations.--In prioritizing areas under 
     paragraph (1), the Director shall consider--
       ``(A) the priorities established under section 1191 of the 
     Social Security Act; and
       ``(B) the key health indicators identified by the Assistant 
     Secretary for Health Information under section 1709.
       ``(3) Limitations.--In conducting its duties under this 
     subsection, the Center for Quality Improvement shall not 
     develop quality-adjusted life year measures or any other 
     methodologies that can be used to deny benefits to a 
     beneficiary against the beneficiary's wishes on the basis of 
     the beneficiary's age, life expectancy, present or predicted 
     disability, or expected quality of life.
       ``(c) Other Responsibilities.--The Director, acting 
     directly or by awarding a grant or contract to an eligible 
     entity, shall--
       ``(1) identify existing best practices under subsection 
     (e);
       ``(2) develop new best practices under subsection (f);
       ``(3) evaluate best practices under subsection (g);
       ``(4) implement best practices under subsection (h);
       ``(5) ensure that best practices are identified, developed, 
     evaluated, and implemented under this section consistent with 
     standards adopted by the Secretary under section 3004 for 
     health information technology used in the collection and 
     reporting of quality information (including for purposes of 
     the demonstration of meaningful use of certified electronic 
     health record (EHR) technology by physicians and hospitals 
     under the Medicare program (under sections 1848(o)(2) and 
     1886(n)(3), respectively, of the Social Security Act)); and
       ``(6) provide for dissemination of information and 
     reporting under subsections (i) and (j).
       ``(d) Eligibility.--To be eligible for a grant or contract 
     under subsection (c), an entity shall--
       ``(1) be a nonprofit entity;
       ``(2) agree to work with a variety of institutional health 
     care providers, physicians, nurses, and other health care 
     practitioners; and
       ``(3) if the entity is not the organization holding a 
     contract under section 1153 of the Social Security Act for 
     the area to be served, agree to cooperate with and avoid 
     duplication of the activities of such organization.
       ``(e) Identifying Existing Best Practices.--The Director 
     shall identify best practices that are--
       ``(1) currently utilized by health care providers 
     (including hospitals, physician and other clinician 
     practices, community cooperatives, and other health care 
     entities) that deliver consistently high-quality, efficient 
     health care services; and
       ``(2) easily adapted for use by other health care providers 
     and for use across a variety of health care settings.
       ``(f) Developing New Best Practices.--The Director shall 
     develop best practices that are--
       ``(1) based on a review of existing scientific evidence;
       ``(2) sufficiently detailed for implementation and 
     incorporation into the workflow of health care providers; and
       ``(3) designed to be easily adapted for use by health care 
     providers across a variety of health care settings.
       ``(g) Evaluation of Best Practices.--The Director shall 
     evaluate best practices identified or developed under this 
     section. Such evaluation--
       ``(1) shall include determinations of which best 
     practices--
       ``(A) most reliably and effectively achieve significant 
     progress in improving the quality of patient care; and
       ``(B) are easily adapted for use by health care providers 
     across a variety of health care settings;
       ``(2) shall include regular review, updating, and 
     improvement of such best practices; and
       ``(3) may include in-depth case studies or empirical 
     assessments of health care providers (including hospitals, 
     physician and other clinician practices, community 
     cooperatives, and other health care entities) and simulations 
     of such best practices for determinations under paragraph 
     (1).
       ``(h) Implementation of Best Practices.--
       ``(1) In general.--The Director shall enter into 
     arrangements with entities in a State or region to implement 
     best practices identified or developed under this section. 
     Such implementation--
       ``(A) may include forming collaborative multi-institutional 
     teams; and
       ``(B) shall include an evaluation of the best practices 
     being implemented, including the measurement of patient 
     outcomes before, during, and after implementation of such 
     best practices.
       ``(2) Preferences.--In carrying out this subsection, the 
     Director shall give priority to health care providers 
     implementing best practices that--
       ``(A) have the greatest impact on patient outcomes and 
     satisfaction;
       ``(B) are the most easily adapted for use by health care 
     providers across a variety of health care settings;
       ``(C) promote coordination of health care practitioners 
     across the continuum of care; and
       ``(D) engage patients and their families in improving 
     patient care and outcomes.
       ``(i) Public Dissemination of Information.--The Director 
     shall provide for the public dissemination of information 
     with respect to best practices and activities under this 
     section. Such information shall be made available in 
     appropriate formats and languages to reflect the varying 
     needs of consumers and diverse levels of health literacy.
       ``(j) Report.--
       ``(1) In general.--The Director shall submit an annual 
     report to the Congress and the Secretary on activities under 
     this section.
       ``(2) Content.--Each report under paragraph (1) shall 
     include--
       ``(A) information on activities conducted pursuant to 
     grants and contracts awarded;
       ``(B) summary data on patient outcomes before, during, and 
     after implementation of best practices; and
       ``(C) recommendations on the adaptability of best practices 
     for use by health providers.''.
       (b) Initial Quality Improvement Activities and Initiatives 
     To Be Implemented.--Until the Director of the Agency for 
     Healthcare Research and Quality has established initial 
     priorities under section 931(b) of the Public Health Service 
     Act, as added by subsection (a), the Director shall, for 
     purposes of such section, prioritize the following:
       (1) Health care-associated infections.--Reducing health 
     care-associated infections, including infections in nursing 
     homes and outpatient settings.
       (2) Surgery.--Increasing hospital and outpatient 
     perioperative patient safety, including reducing surgical-
     site infections and surgical errors (such as wrong-site 
     surgery and retained foreign bodies).
       (3) Emergency room.--Improving care in hospital emergency 
     rooms, including through the use of principles of efficiency 
     of design and delivery to improve patient flow.
       (4) Obstetrics.--Improving the provision of obstetrical and 
     neonatal care, including the identification of interventions 
     that are effective in reducing the risk of preterm and 
     premature labor and the implementation of best practices for 
     labor and delivery care.
       (5) Pediatrics.--Improving the provision of preventive and 
     developmental child health services, including interventions 
     that can reduce child health disparities (as defined in 
     section 3171 of the Public Health Service Act, as added by 
     section 2301) and reduce the risk of developing chronic 
     health-threatening conditions that affect an individual's 
     life course development.
       (c) Report.--Not later than 18 months after the date of the 
     enactment of this Act, the Director of the Agency for 
     Healthcare Research and Quality shall submit a report to the 
     Congress on the impact of the nurse-to-patient ratio on the 
     quality of care and patient outcomes, including 
     recommendations for further integration into quality 
     measurement and quality improvement activities.

     SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

       (a) Establishment.--Title XVII (42 U.S.C. 300u et seq.) is 
     amended--
       (1) by redesignating sections 1709 and 1710 as sections 
     1710 and 1711, respectively; and
       (2) by inserting after section 1708 the following:

     ``SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

       ``(a) In General.--There is established within the 
     Department an Assistant Secretary for Health Information (in 
     this section referred to as the `Assistant Secretary'), to be 
     appointed by the Secretary.
       ``(b) Responsibilities.--The Assistant Secretary shall--
       ``(1) ensure the collection, collation, reporting, and 
     publishing of information (including full and complete 
     statistics) on key health indicators regarding the Nation's 
     health and the performance of the Nation's health care;
       ``(2) facilitate and coordinate the collection, collation, 
     reporting, and publishing of information regarding the 
     Nation's health and the performance of the Nation's health 
     care (other than information described in paragraph (1));
       ``(3)(A) develop standards for the collection of data 
     regarding the Nation's health and the performance of the 
     Nation's health care; and
       ``(B) in carrying out subparagraph (A)--
       ``(i) ensure appropriate specificity and standardization 
     for data collection at the national, regional, State, and 
     local levels;

[[Page 27359]]

       ``(ii) include standards, as appropriate, for the 
     collection of accurate data on health disparities;
       ``(iii) ensure, with respect to data on race and ethnicity, 
     consistency with the 1997 Office of Management and Budget 
     Standards for Maintaining, Collecting and Presenting Federal 
     Data on Race and Ethnicity (or any successor standards); and
       ``(iv) in consultation with the Director of the Office of 
     Minority Health, and the Director of the Office of Civil 
     Rights of the Department, develop standards for the 
     collection of data on health and health care with respect to 
     primary language;
       ``(4) provide support to Federal departments and agencies 
     whose programs have a significant impact upon health (as 
     determined by the Secretary) for the collection and collation 
     of information described in paragraphs (1) and (2);
       ``(5) ensure the sharing of information described in 
     paragraphs (1) and (2) among the agencies of the Department;
       ``(6) facilitate the sharing of information described in 
     paragraphs (1) and (2) by Federal departments and agencies 
     whose programs have a significant impact upon health (as 
     determined by the Secretary);
       ``(7) identify gaps in information described in paragraphs 
     (1) and (2) and the appropriate agency or entity to address 
     such gaps;
       ``(8) facilitate and coordinate identification and 
     monitoring of health disparities by the agencies of the 
     Department to inform program and policy efforts to reduce 
     such disparities, including facilitating and funding analyses 
     conducted in cooperation with the Social Security 
     Administration, the Bureau of the Census, and other 
     appropriate agencies and entities;
       ``(9) consistent with privacy, proprietary, and other 
     appropriate safeguards, facilitate public accessibility of 
     datasets (such as de-identified Medicare datasets or publicly 
     available data on key health indicators) by means of the 
     Internet; and
       ``(10) award grants or contracts for the collection and 
     collation of information described in paragraphs (1) and (2) 
     (including through statewide surveys that provide 
     standardized information).
       ``(c) Key Health Indicators.--
       ``(1) In general.--In carrying out subsection (b)(1), the 
     Assistant Secretary shall--
       ``(A) identify, and reassess at least once every 3 years, 
     key health indicators described in such subsection;
       ``(B) publish statistics on such key health indicators for 
     the public--
       ``(i) not less than annually; and
       ``(ii) on a supplemental basis whenever warranted by--

       ``(I) the rate of change for a key health indicator; or
       ``(II) the need to inform policy regarding the Nation's 
     health and the performance of the Nation's health care; and

       ``(C) ensure consistency with the national strategy 
     developed by the Secretary under section 3121 and 
     consideration of the indicators specified in the reports 
     under sections 308, 903(a)(6), and 913(b)(2).
       ``(2) Release of key health indicators.--The regulations, 
     rules, processes, and procedures of the Office of Management 
     and Budget governing the review, release, and dissemination 
     of key health indicators shall be the same as the 
     regulations, rules, processes, and procedures of the Office 
     of Management and Budget governing the review, release, and 
     dissemination of Principal Federal Economic Indicators (or 
     equivalent statistical data) by the Bureau of Labor 
     Statistics.
       ``(d) Coordination.--In carrying out this section, the 
     Assistant Secretary shall coordinate with--
       ``(1) public and private entities that collect and 
     disseminate information on health and health care, including 
     foundations; and
       ``(2) the head of the Office of the National Coordinator 
     for Health Information Technology to ensure optimal use of 
     health information technology.
       ``(e) Request for Information From Departments and 
     Agencies.--Consistent with applicable law, the Assistant 
     Secretary may secure directly from any Federal department or 
     agency information necessary to enable the Assistant 
     Secretary to carry out this section.
       ``(f) Report.--
       ``(1) Submission.--The Assistant Secretary shall submit to 
     the Secretary and the Congress an annual report containing--
       ``(A) a description of national, regional, or State changes 
     in health or health care, as reflected by the key health 
     indicators identified under subsection (c)(1);
       ``(B) a description of gaps in the collection, collation, 
     reporting, and publishing of information regarding the 
     Nation's health and the performance of the Nation's health 
     care;
       ``(C) recommendations for addressing such gaps and 
     identification of the appropriate agency within the 
     Department or other entity to address such gaps;
       ``(D) a description of analyses of health disparities, 
     including the results of completed analyses, the status of 
     ongoing longitudinal studies, and proposed or planned 
     research; and
       ``(E) a plan for actions to be taken by the Assistant 
     Secretary to address gaps described in subparagraph (B).
       ``(2) Consideration.--In preparing a report under paragraph 
     (1), the Assistant Secretary shall take into consideration 
     the findings and conclusions in the reports under sections 
     308, 903(a)(6), and 913(b)(2).
       ``(g) Proprietary and Privacy Protections.--Nothing in this 
     section shall be construed to affect applicable proprietary 
     or privacy protections.
       ``(h) Consultation.--In carrying out this section, the 
     Assistant Secretary shall consult with--
       ``(1) the heads of appropriate health agencies and offices 
     in the Department, including the Office of the Surgeon 
     General of the Public Health Service, the Office of Minority 
     Health, and the Office on Women's Health; and
       ``(2) as appropriate, the heads of other Federal 
     departments and agencies whose programs have a significant 
     impact upon health (as determined by the Secretary).
       ``(i) Definition.--In this section:
       ``(1) The terms `agency' and `agencies' include an 
     epidemiology center established under section 214 of the 
     Indian Health Care Improvement Act.
       ``(2) The term `Department' means the Department of Health 
     and Human Services.
       ``(3) The term `health disparities' has the meaning given 
     to such term in section 3171.''.
       (b) Other Coordination Responsibilities.--Title III (42 
     U.S.C. 241 et seq.) is amended--
       (1) in paragraphs (1) and (2) of section 304(c) (42 U.S.C. 
     242b(c)), by inserting ``, acting through the Assistant 
     Secretary for Health Information,'' after ``The Secretary'' 
     each place it appears; and
       (2) in section 306(j) (42 U.S.C. 242k(j)), by inserting ``, 
     acting through the Assistant Secretary for Health 
     Information,'' after ``of this section, the Secretary''.

     SEC. 2403. AUTHORIZATION OF APPROPRIATIONS.

       Section 799C, as added and amended, is further amended by 
     adding at the end the following:
       ``(e) Quality and Surveillance.--For the purpose of 
     carrying out part D of title IX and section 1709, in addition 
     to any other amounts authorized to be appropriated for such 
     purpose, there are authorized to be appropriated, out of any 
     monies in the Public Health Investment Fund, $300,000,000 for 
     each of fiscal years 2011 through 2015.''.

                       TITLE V--OTHER PROVISIONS

 Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program 
                               Integrity

     SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM.

       (a) Expansion of Covered Entities Receiving Discounted 
     Prices.--Section 340B(a)(4) (42 U.S.C. 256b(a)(4)) is amended 
     by adding at the end the following:
       ``(M) A children's hospital excluded from the Medicare 
     prospective payment system pursuant to section 
     1886(d)(1)(B)(iii) of the Social Security Act, or a free-
     standing cancer hospital excluded from the Medicare 
     prospective payment system pursuant to section 
     1886(d)(1)(B)(v) of the Social Security Act that would meet 
     the requirements of subparagraph (L), including the 
     disproportionate share adjustment percentage requirement 
     under clause (ii) of such subparagraph, if the hospital were 
     a subsection (d) hospital as defined by section 1886(d)(1)(B) 
     of the Social Security Act.
       ``(N) An entity that is a critical access hospital (as 
     determined under section 1820(c)(2) of the Social Security 
     Act).
       ``(O) An entity receiving funds under title V of the Social 
     Security Act (relating to maternal and child health) for the 
     provision of health services.
       ``(P) An entity receiving funds under subpart I of part B 
     of title XIX of the Public Health Service Act (relating to 
     comprehensive mental health services) for the provision of 
     community mental health services.
       ``(Q) An entity receiving funds under subpart II of such 
     part B (relating to the prevention and treatment of substance 
     abuse) for the provision of treatment services for substance 
     abuse.
       ``(R) An entity that is a Medicare-dependent, small rural 
     hospital (as defined in section 1886(d)(5)(G)(iv) of the 
     Social Security Act).
       ``(S) An entity that is a sole community hospital (as 
     defined in section 1886(d)(5)(D)(iii) of the Social Security 
     Act).
       ``(T) An entity that is classified as a rural referral 
     center under section 1886(d)(5)(C) of the Social Security 
     Act.''.
       (b) Prohibition on Group Purchasing Arrangements.--Section 
     340B(a) (42 U.S.C. 256b(a)) is amended--
       (1) in paragraph (4)(L)--
       (A) by adding ``and'' at the end of clause (i);
       (B) by striking ``; and'' at the end of clause (ii) and 
     inserting a period; and
       (C) by striking clause (iii); and
       (2) in paragraph (5), by redesignating subparagraphs (C) 
     and (D) as subparagraphs (D) and (E), respectively, and by 
     inserting after subparagraph (B) the following:
       ``(C) Prohibiting use of group purchasing arrangements.--A 
     hospital described in subparagraph (L), (M), (N), (R), (S), 
     or (T) of paragraph (4) shall not obtain covered outpatient 
     drugs through a group purchasing organization or other group 
     purchasing arrangement.''.

[[Page 27360]]



     SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.

       (a) Integrity Improvements.--Section 340B (42 U.S.C. 256b) 
     is amended--
       (1) by striking subsections (c) and (d); and
       (2) by inserting after subsection (b) the following:
       ``(c) Improvements in Program Integrity.--
       ``(1) Manufacturer compliance.--
       ``(A) In general.--From amounts appropriated under 
     paragraph (4), the Secretary shall provide for improvements 
     in compliance by manufacturers with the requirements of this 
     section in order to prevent overcharges and other violations 
     of the discounted pricing requirements specified in this 
     section.
       ``(B) Improvements.--The improvements described in 
     subparagraph (A) shall include the following:
       ``(i) The establishment of a process to enable the 
     Secretary to verify the accuracy of ceiling prices calculated 
     by manufacturers under subsection (a)(1) and charged to 
     covered entities, which shall include the following:

       ``(I) Developing and publishing, through an appropriate 
     policy or regulatory issuance, standards and methodology for 
     the calculation of ceiling prices under such subsection.
       ``(II) Comparing regularly the ceiling prices calculated by 
     the Secretary with the quarterly pricing data that is 
     reported by manufacturers to the Secretary.
       ``(III) Conducting periodic monitoring of sales 
     transactions to covered entities.
       ``(IV) Inquiring into any discrepancies between ceiling 
     prices and manufacturer pricing data that may be identified 
     and taking, or requiring manufacturers to take, corrective 
     action in response to such discrepancies, including the 
     issuance of refunds pursuant to the procedures set forth in 
     clause (ii).

       ``(ii) The establishment of procedures for the issuance of 
     refunds to covered entities by manufacturers in the event 
     that the Secretary finds there has been an overcharge, 
     including the following:

       ``(I) Submission to the Secretary by manufacturers of an 
     explanation of why and how the overcharge occurred, how the 
     refunds will be calculated, and to whom the refunds will be 
     issued.
       ``(II) Oversight by the Secretary to ensure that the 
     refunds are issued accurately and within a reasonable period 
     of time.

       ``(iii) Notwithstanding any other provision of law 
     prohibiting the disclosure of ceiling prices or data used to 
     calculate the ceiling price, the provision of access to 
     covered entities and State Medicaid agencies through an 
     Internet website of the Department of Health and Human 
     Services or contractor to the applicable ceiling prices for 
     covered drugs as calculated and verified by the Secretary in 
     a manner that ensures protection of privileged pricing data 
     from unauthorized disclosure.
       ``(iv) The development of a mechanism by which--

       ``(I) rebates, discounts, or other price concessions 
     provided by manufacturers to other purchasers subsequent to 
     the sale of covered drugs to covered entities are reported to 
     the Secretary; and
       ``(II) appropriate credits and refunds are issued to 
     covered entities if such rebates, discounts, or other price 
     concessions have the effect of lowering the applicable 
     ceiling price for the relevant quarter for the drugs 
     involved.

       ``(v) In addition to authorities under section 1927(b)(3) 
     of the Social Security Act, the Secretary may conduct audits 
     of manufacturers and wholesalers to ensure the integrity of 
     the program under this section, including audits on the 
     market price of covered drugs.
       ``(vi) The establishment of a requirement that 
     manufacturers and wholesalers use the identification system 
     developed by the Secretary for purposes of facilitating the 
     ordering, purchasing, and delivery of covered drugs under 
     this section, including the processing of chargebacks for 
     such drugs.
       ``(vii) The imposition of sanctions in the form of civil 
     monetary penalties, which--

       ``(I) shall be assessed according to standards and 
     procedures established in regulations to be promulgated by 
     the Secretary within one year of the date of the enactment of 
     the Affordable Health Care for America Act; and
       ``(II) shall apply to any manufacturer with an agreement 
     under this section and shall not exceed $100,000 for each 
     instance where a manufacturer knowingly charges a covered 
     entity a price for purchase of a drug that exceeds the 
     maximum applicable price under subsection (a)(1) or that 
     knowingly violates any other provision of this section, or 
     withholds or provides false information to the Secretary or 
     to covered entities under this section.

       ``(2) Covered entity compliance.--
       ``(A) In general.--From amounts appropriated under 
     paragraph (4), the Secretary shall provide for improvements 
     in compliance by covered entities with the requirements of 
     this section in order to prevent diversion and violations of 
     the duplicate discount provision and other requirements under 
     subsection (a)(5).
       ``(B) Improvements.--The improvements described in 
     subparagraph (A) shall include the following:
       ``(i) The development of procedures to enable and require 
     covered entities to update at least annually the information 
     on the Internet Web site of the Department of Health and 
     Human Services relating to this section.
       ``(ii) The development of procedures for the Secretary to 
     verify the accuracy of information regarding covered entities 
     that is listed on the Web site described in clause (i).
       ``(iii) The development of more detailed guidance 
     describing methodologies and options available to covered 
     entities for billing covered drugs to State Medicaid agencies 
     in a manner that avoids duplicate discounts pursuant to 
     subsection (a)(5)(A).
       ``(iv) The establishment of a single, universal, and 
     standardized identification system by which each covered 
     entity site can be identified by manufacturers, distributors, 
     covered entities, and the Secretary for purposes of 
     facilitating the ordering, purchasing, and delivery of 
     covered drugs under this section, including the processing of 
     chargebacks for such drugs.
       ``(v) The imposition of sanctions in the form of civil 
     monetary penalties, which--

       ``(I) shall be assessed according to standards and 
     procedures established in regulations promulgated by the 
     Secretary;
       ``(II) shall not exceed $5,000 for each violation; and
       ``(III) shall apply to any covered entity that knowingly 
     violates subparagraph (a)(5)(B) or knowingly violates any 
     other provision of this section.

       ``(vi) The exclusion of a covered entity from participation 
     in the program under this section, for a period of time to be 
     determined by the Secretary, in cases in which the Secretary 
     determines, in accordance with standards and procedures 
     established in regulations, that--

       ``(I) a violation of a requirement of this section was 
     repeated and knowing; and
       ``(II) imposition of a monetary penalty would be 
     insufficient to reasonably ensure compliance.

       ``(vii) The referral of matters as appropriate to the Food 
     and Drug Administration, the Office of Inspector General of 
     Department of Health and Human Services, or other Federal 
     agencies.
       ``(3) Administrative dispute resolution process.--From 
     amounts appropriated under paragraph (4), the Secretary may 
     establish and implement an administrative process for the 
     resolution of the following:
       ``(A) Claims by covered entities that manufacturers have 
     violated the terms of their agreement with the Secretary 
     under subsection (a)(1).
       ``(B) Claims by manufacturers that covered entities have 
     violated subsection (a)(5)(A) or (a)(5)(B).
       ``(4) Authorization of appropriations.--There are 
     authorized to be appropriated to carry out this subsection, 
     such sums as may be necessary for fiscal year 2011 and each 
     succeeding fiscal year.''.
       (b) Conforming Amendments.--
       (1) Section 340B(a) (42 U.S.C. 256b(a)) is amended--
       (A) by adding at the end of paragraph (1) the following: 
     ``Such agreement shall require that the manufacturer offer 
     each covered entity covered drugs for purchase at or below 
     the applicable ceiling price if such drug is made available 
     to any other purchaser at any price. Such agreement shall 
     require that, if the supply of a covered drug is insufficient 
     to meet demand, then the manufacturer may utilize an 
     allocation method that is reported in writing to the 
     Secretary and does not discriminate on the basis of the price 
     paid by covered entities or on any other basis related to an 
     entity's participation in the program under this section. 
     Notwithstanding any other provision of law, if the Secretary 
     requests a manufacturer to enter into a new or amended 
     agreement under this section that complies with current law 
     and if the manufacturer opts not to sign the new or amended 
     agreement, then any existing agreement between the 
     manufacturer and the Secretary under this section is deemed 
     to no longer meet the requirements of this section for 
     purposes of this section and section 1927 of the Social 
     Security Act.''; and
       (B) by adding at the end the following paragraph:
       ``(11) Quarterly reports.--An agreement described in 
     paragraph (1) shall require that the manufacturer furnish the 
     Secretary with reports on a quarterly basis that include the 
     following information:
       ``(A) The price for each covered drug subject to the 
     agreement that, according to the manufacturer, represents the 
     maximum price that covered entities may permissibly be 
     required to pay for the drug (referred to in this section as 
     the `ceiling price').
       ``(B) The component information used to calculate the 
     ceiling price as determined necessary to administer the 
     requirements of the program under this section.
       ``(C) Rebates, discounts, and other price concessions 
     provided by manufacturers to other purchasers subsequent to 
     the sale of covered drugs to covered entities.''.
       (2) Section 1927(a)(5) of the Social Security Act (42 
     U.S.C. 1396r-8(a)(5)) is amended by striking subparagraph 
     (D).

     SEC. 2503. EFFECTIVE DATE.

       (a) In General.--The amendments made by this subtitle shall 
     take effect on the date of

[[Page 27361]]

     the enactment of this Act, and sections 2501, 2502(a)(1), and 
     2502(b)(2) shall apply to drugs dispensed on or after such 
     date.
       (b) Effectiveness.--The amendments made by this subtitle 
     shall be effective, and shall be taken into account in 
     determining whether a manufacturer is deemed to meet the 
     requirements of section 340B(a) of the Public Health Service 
     Act (42 U.S.C. 256b(a)), and of section 1927(a)(5) of the 
     Social Security Act (42 U.S.C. 1396r-8(a)(5)), 
     notwithstanding any other provision of law.

                          Subtitle B--Programs

                 PART 1--GRANTS FOR CLINICS AND CENTERS

     SEC. 2511. SCHOOL-BASED HEALTH CLINICS.

       (a) In General.--Part Q of title III (42 U.S.C. 280h et 
     seq.) is amended by adding at the end the following:

     ``SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS.

       ``(a) Program.--The Secretary shall establish a school-
     based health clinic program consisting of awarding grants to 
     eligible entities to support the operation of school-based 
     health clinics (referred to in this section as `SBHCs').
       ``(b) Eligibility.--To be eligible for a grant under this 
     section, an entity shall--
       ``(1) be an SBHC (as defined in subsection (l)(3)); and
       ``(2) submit an application at such time, in such manner, 
     and containing such information as the Secretary may require, 
     including at a minimum--
       ``(A) evidence that the applicant meets all criteria 
     necessary to be designated as an SBHC;
       ``(B) evidence of local need for the services to be 
     provided by the SBHC;
       ``(C) an assurance that--
       ``(i) SBHC services will be provided in accordance with 
     Federal, State, and local laws;
       ``(ii) the SBHC has established and maintains collaborative 
     relationships with other health care providers in the 
     catchment area of the SBHC;
       ``(iii) the SBHC will provide onsite access during the 
     academic day when school is in session and has an established 
     network of support and access to services with backup health 
     providers when the school or SBHC is closed;
       ``(iv) the SBHC will be integrated into the school 
     environment and will coordinate health services with 
     appropriate school personnel and other community providers 
     co-located at the school; and
       ``(v) the SBHC sponsoring facility assumes all 
     responsibility for the SBHC administration, operations, and 
     oversight; and
       ``(D) such other information as the Secretary may require.
       ``(c) Use of Funds.--Funds awarded under a grant under this 
     section--
       ``(1) may be used for--
       ``(A) providing training related to the provision of 
     comprehensive primary health services and additional health 
     services;
       ``(B) the management and operation of SBHC programs, 
     including through subcontracts; and
       ``(C) the payment of salaries for health professionals and 
     other appropriate SBHC personnel; and
       ``(2) may not be used to provide abortions.
       ``(d) Consideration of Need.--In determining the amount of 
     a grant under this section, the Secretary shall take into 
     consideration--
       ``(1) the financial need of the SBHC;
       ``(2) State, local, or other sources of funding provided to 
     the SBHC; and
       ``(3) other factors as determined appropriate by the 
     Secretary.
       ``(e) Preferences.--In awarding grants under this section, 
     the Secretary shall give preference to SBHCs that have a 
     demonstrated record of service to at least one of the 
     following:
       ``(1) A high percentage of medically underserved children 
     and adolescents.
       ``(2) Communities or populations in which children and 
     adolescents have difficulty accessing health and mental 
     health services.
       ``(3) Communities with high percentages of children and 
     adolescents who are uninsured, underinsured, or eligible for 
     medical assistance under Federal or State health benefits 
     programs (including titles XIX and XXI of the Social Security 
     Act).
       ``(f) Matching Requirement.--The Secretary may award a 
     grant to an SBHC under this section only if the SBHC agrees 
     to provide, from non-Federal sources, an amount equal to 20 
     percent of the amount of the grant (which may be provided in 
     cash or in kind) to carry out the activities supported by the 
     grant.
       ``(g) Supplement, Not Supplant.--The Secretary may award a 
     grant to an SBHC under this section only if the SBHC 
     demonstrates to the satisfaction of the Secretary that funds 
     received through the grant will be expended only to 
     supplement, and not supplant, non-Federal and Federal funds 
     otherwise available to the SBHC for operation of the SBHC 
     (including each activity described in paragraph (1) or (2) of 
     subsection (c)).
       ``(h) Payor of Last Resort.--The Secretary may award a 
     grant to an SBHC under this section only if the SBHC 
     demonstrates to the satisfaction of the Secretary that funds 
     received through the grant will not be expended for any 
     activity to the extent that payment has been made, or can 
     reasonably be expected to be made--
       ``(1) under any insurance policy;
       ``(2) under any Federal or State health benefits program 
     (including titles XIX and XXI of the Social Security Act); or
       ``(3) by an entity which provides health services on a 
     prepaid basis.
       ``(i) Regulations Regarding Reimbursement for Health 
     Services.--The Secretary shall issue regulations regarding 
     the reimbursement for health services provided by SBHCs to 
     individuals eligible to receive such services through the 
     program under this section, including reimbursement under any 
     insurance policy or any Federal or State health benefits 
     program (including titles XIX and XXI of the Social Security 
     Act).
       ``(j) Technical Assistance.--The Secretary shall provide 
     (either directly or by grant or contract) technical and other 
     assistance to SBHCs to assist such SBHCs to meet the 
     requirements of this section. Such assistance may include 
     fiscal and program management assistance, training in fiscal 
     and program management, operational and administrative 
     support, and the provision of information to the SBHCs of the 
     variety of resources available under this title and how those 
     resources can be best used to meet the health needs of the 
     communities served by the SBHCs.
       ``(k) Evaluation; Report.--The Secretary shall--
       ``(1) develop and implement a plan for evaluating SBHCs and 
     monitoring quality performances under the awards made under 
     this section; and
       ``(2) submit to the Congress on an annual basis a report on 
     the program under this section.
       ``(l) Definitions.--In this section:
       ``(1) Comprehensive primary health services.--The term 
     `comprehensive primary health services' means the core 
     services offered by SBHCs, which--
       ``(A) shall include--
       ``(i) comprehensive health assessments, diagnosis, and 
     treatment of minor, acute, and chronic medical conditions and 
     referrals to, and followup for, specialty care; and
       ``(ii) mental health assessments, crisis intervention, 
     counseling, treatment, and referral to a continuum of 
     services including emergency psychiatric care, community 
     support programs, inpatient care, and outpatient programs; 
     and
       ``(B) may include additional services, such as oral health, 
     social, and age-appropriate health education services, 
     including nutritional counseling.
       ``(2) Medically underserved children and adolescents.--The 
     term `medically underserved children and adolescents' means a 
     population of children and adolescents who are residents of 
     an area designated by the Secretary as an area with a 
     shortage of personal health services and health 
     infrastructure for such children and adolescents.
       ``(3) School-based health clinic.--The term `school-based 
     health clinic' means a health clinic that--
       ``(A) is located in, or is adjacent to, a school facility 
     of a local educational agency;
       ``(B) is organized through school, community, and health 
     provider relationships;
       ``(C) is administered by a sponsoring facility;
       ``(D) provides comprehensive primary health services during 
     school hours to children and adolescents by health 
     professionals in accordance with State and local laws and 
     regulations, established standards, and community practice; 
     and
       ``(E) does not perform abortion services.
       ``(4) Sponsoring facility.--The term `sponsoring facility' 
     is--
       ``(A) a hospital;
       ``(B) a public health department;
       ``(C) a community health center;
       ``(D) a nonprofit health care entity whose mission is to 
     provide access to comprehensive primary health care services;
       ``(E) a local educational agency; or
       ``(F) a program administered by the Indian Health Service 
     or the Bureau of Indian Affairs or operated by an Indian 
     tribe or a tribal organization under the Indian Self-
     Determination and Education Assistance Act, a Native Hawaiian 
     entity, or an urban Indian program under title V of the 
     Indian Health Care Improvement Act.
       ``(m) Authorization of Appropriations.--For purposes of 
     carrying out this section, there are authorized to be 
     appropriated $50,000,000 for fiscal year 2011 and such sums 
     as may be necessary for each of fiscal years 2012 through 
     2015.''.
       (b) Effective Date.--The Secretary of Health and Human 
     Services shall begin awarding grants under section 399Z-1 of 
     the Public Health Service Act, as added by subsection (a), 
     not later than July 1, 2010, without regard to whether or not 
     final regulations have been issued under section 399Z-1(i) of 
     such Act.
       (c) Termination of Study.--Section 2(b) of the Health Care 
     Safety Net Act of 2008 (42 U.S.C. 254b note) is amended by 
     striking paragraph (2) (relating to a school-based health 
     center study).

     SEC. 2512. NURSE-MANAGED HEALTH CENTERS.

       Title III (42 U.S.C. 241 et seq.) is amended by adding at 
     the end the following:

[[Page 27362]]



                 ``PART S--NURSE-MANAGED HEALTH CENTERS

     ``SEC. 399FF. NURSE-MANAGED HEALTH CENTERS.

       ``(a) Program.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration, shall establish a nurse-managed health center 
     program consisting of awarding grants to entities under 
     subsection (b).
       ``(b) Grant.--The Secretary shall award grants to 
     entities--
       ``(1) to plan and develop a nurse-managed health center; or
       ``(2) to operate a nurse-managed health center.
       ``(c) Use of Funds.--Amounts received as a grant under 
     subsection (b) may be used for activities including the 
     following:
       ``(1) Purchasing or leasing equipment.
       ``(2) Training and technical assistance related to the 
     provision of comprehensive primary care services and wellness 
     services.
       ``(3) Other activities for planning, developing, or 
     operating, as applicable, a nurse-managed health center.
       ``(d) Assurances Applicable to Both Planning and Operation 
     Grants.--
       ``(1) In general.--The Secretary may award a grant under 
     this section to an entity only if the entity demonstrates to 
     the Secretary's satisfaction that--
       ``(A) nurses, in addition to managing the center, will be 
     adequately represented as providers at the center; and
       ``(B) not later than 90 days after receiving the grant, the 
     entity will establish a community advisory committee composed 
     of individuals, a majority of whom are being served by the 
     center, to provide input into the nurse-managed health 
     center's operations.
       ``(2) Matching requirement.--The Secretary may award a 
     grant under this section to an entity only if the entity 
     agrees to provide, from non-Federal sources, an amount equal 
     to 20 percent of the amount of the grant (which may be 
     provided in cash or in kind) to carry out the activities 
     supported by the grant.
       ``(3) Payor of last resort.--The Secretary may award a 
     grant under this section to an entity only if the entity 
     demonstrates to the satisfaction of the Secretary that funds 
     received through the grant will not be expended for any 
     activity to the extent that payment has been made, or can 
     reasonably be expected to be made--
       ``(A) under any insurance policy;
       ``(B) under any Federal or State health benefits program 
     (including titles XIX and XXI of the Social Security Act); or
       ``(C) by an entity which provides health services on a 
     prepaid basis.
       ``(4) Maintenance of effort.--The Secretary may award a 
     grant under this section to an entity only if the entity 
     demonstrates to the satisfaction of the Secretary that--
       ``(A) funds received through the grant will be expended 
     only to supplement, and not supplant, non-Federal and Federal 
     funds otherwise available to the entity for the activities to 
     be funded through the grant; and
       ``(B) with respect to such activities, the entity will 
     maintain expenditures of non-Federal amounts for such 
     activities at a level not less than the lesser of such 
     expenditures maintained by the entity for the fiscal year 
     preceding the fiscal year for which the entity receives the 
     grant.
       ``(e) Additional Assurance for Planning Grants.--The 
     Secretary may award a grant under subsection (b)(1) to an 
     entity only if the entity agrees--
       ``(1) to assess the needs of the medically underserved 
     populations proposed to be served by the nurse-managed health 
     center; and
       ``(2) to design services and operations of the nurse-
     managed health center for such populations based on such 
     assessment.
       ``(f) Additional Assurance for Operation Grants.--The 
     Secretary may award a grant under subsection (b)(2) to an 
     entity only if the entity assures that the nurse-managed 
     health center will provide--
       ``(1) comprehensive primary care services, wellness 
     services, and other health care services deemed appropriate 
     by the Secretary;
       ``(2) care without respect to insurance status or income of 
     the patient; and
       ``(3) direct access to client-centered services offered by 
     advanced practice nurses, other nurses, physicians, physician 
     assistants, or other qualified health professionals.
       ``(g) Technical Assistance.--The Secretary shall provide 
     (either directly or by grant or contract) technical and other 
     assistance to nurse-managed health centers to assist such 
     centers in meeting the requirements of this section. Such 
     assistance may include fiscal and program management 
     assistance, training in fiscal and program management, 
     operational and administrative support, and the provision of 
     information to nurse-managed health centers regarding the 
     various resources available under this section and how those 
     resources can best be used to meet the health needs of the 
     communities served by nurse-managed health centers.
       ``(h) Report.--The Secretary shall submit to the Congress 
     an annual report on the program under this section.
       ``(i) Definitions.--In this section:
       ``(1) Comprehensive primary care services.--The term 
     `comprehensive primary care services' has the meaning given 
     to the term `required primary health services' in section 
     330(b)(1).
       ``(2) Medically underserved population.--The term 
     `medically underserved population' has the meaning given to 
     such term in section 330(b)(3).
       ``(3) Nurse-managed health center.--The term `nurse-managed 
     health center' has the meaning given to such term in section 
     801.
       ``(4) Wellness services.--The term `wellness services' 
     means any health-related service or intervention, not 
     including primary care, which is designed to reduce 
     identifiable health risks and increase healthy behaviors 
     intended to prevent the onset of disease or lessen the impact 
     of existing chronic conditions by teaching more effective 
     management techniques that focus on individual self-care and 
     patient-driven decisionmaking.
       ``(j) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 
     2015.''.

     SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH CENTERS.

       Section 1913 (42 U.S.C. 300x-3) is amended--
       (1) in subsection (a)(2)(A), by striking ``community mental 
     health services'' and inserting ``behavioral health services 
     (of the type offered by federally qualified behavioral health 
     centers consistent with subsection (c)(3))'';
       (2) in subsection (b)--
       (A) by striking paragraph (1) and inserting the following:
       ``(1) services under the plan will be provided only through 
     appropriate, qualified community programs (which may include 
     federally qualified behavioral health centers, child mental 
     health programs, psychosocial rehabilitation programs, mental 
     health peer-support programs, and mental health primary 
     consumer-directed programs); and''; and
       (B) in paragraph (2), by striking ``community mental health 
     centers'' and inserting ``federally qualified behavioral 
     health centers''; and
       (3) by striking subsection (c) and inserting the following:
       ``(c) Criteria for Federally Qualified Behavioral Health 
     Centers.--
       ``(1) In general.--The Administrator shall certify, and 
     recertify at least every 5 years, federally qualified 
     behavioral health centers as meeting the criteria specified 
     in this subsection.
       ``(2) Regulations.--Not later than 18 months after the date 
     of the enactment of the Affordable Health Care for America 
     Act, the Administrator shall issue final regulations for 
     certifying centers under paragraph (1).
       ``(3) Criteria.--The criteria referred to in subsection 
     (b)(2) are that the center performs each of the following:
       ``(A) Provide services in locations that ensure services 
     will be available and accessible promptly and in a manner 
     which preserves human dignity and assures continuity of care.
       ``(B) Provide services in a mode of service delivery 
     appropriate for the target population.
       ``(C) Provide individuals with a choice of service options 
     where there is more than one efficacious treatment.
       ``(D) Employ a core staff of clinical staff that is 
     multidisciplinary and culturally and linguistically 
     competent.
       ``(E) Provide services, within the limits of the capacities 
     of the center, to any individual residing or employed in the 
     service area of the center.
       ``(F) Provide, directly or through contract, to the extent 
     covered for adults in the State Medicaid plan and for 
     children in accordance with section 1905(r) of the Social 
     Security Act regarding early and periodic screening, 
     diagnosis, and treatment, each of the following services:
       ``(i) Screening, assessment, and diagnosis, including risk 
     assessment.
       ``(ii) Person-centered treatment planning or similar 
     processes, including risk assessment and crisis planning.
       ``(iii) Outpatient clinic mental health services, including 
     screening, assessment, diagnosis, psychotherapy, substance 
     abuse counseling, medication management, and integrated 
     treatment for mental illness and substance abuse which shall 
     be evidence-based (including cognitive behavioral therapy, 
     dialectical behavioral therapy, motivational interviewing, 
     and other such therapies which are evidence-based).
       ``(iv) Outpatient clinic primary care services, including 
     screening and monitoring of key health indicators and health 
     risk (including screening for diabetes, hypertension, and 
     cardiovascular disease and monitoring of weight, height, body 
     mass index (BMI), blood pressure, blood glucose or HbA1C, and 
     lipid profile).
       ``(v) Crisis mental health services, including 24-hour 
     mobile crisis teams, emergency crisis intervention services, 
     and crisis stabilization.
       ``(vi) Targeted case management (services to assist 
     individuals gaining access to needed medical, social, 
     educational, and other services and applying for income 
     security and other benefits to which they may be entitled).

[[Page 27363]]

       ``(vii) Psychiatric rehabilitation services including 
     skills training, assertive community treatment, family 
     psychoeducation, disability self-management, supported 
     employment, supported housing services, therapeutic foster 
     care services, multisystemic therapy, and such other 
     evidence-based practices as the Secretary may require.
       ``(viii) Peer support and counselor services and family 
     supports.
       ``(G) Maintain linkages, and where possible enter into 
     formal contracts with, inpatient psychiatric facilities and 
     substance abuse detoxification and residential programs.
       ``(H) Make available to individuals served by the center, 
     directly, through contract, or through linkages with other 
     programs, each of the following:
       ``(i) Adult and youth peer support and counselor services.
       ``(ii) Family support services for families of children 
     with serious mental disorders.
       ``(iii) Other community or regional services, supports, and 
     providers, including schools, child welfare agencies, 
     juvenile and criminal justice agencies and facilities, 
     housing agencies and programs, employers, and other social 
     services.
       ``(iv) Onsite or offsite access to primary care services.
       ``(v) Enabling services, including outreach, 
     transportation, and translation.
       ``(vi) Health and wellness services, including services for 
     tobacco cessation.''.

                      PART 2--OTHER GRANT PROGRAMS

     SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDUCATION TO 
                   NURSES AND CREATE A PIPELINE TO NURSING.

       (a) Purposes.--It is the purpose of this section to 
     authorize grants to--
       (1) address the projected shortage of nurses by funding 
     comprehensive programs to create a career ladder to nursing 
     (including certified nurse assistants, licensed practical 
     nurses, licensed vocational nurses, and registered nurses) 
     for incumbent ancillary health care workers;
       (2) increase the capacity for educating nurses by 
     increasing both nurse faculty and clinical opportunities 
     through collaborative programs between staff nurse 
     organizations, health care providers, and accredited schools 
     of nursing; and
       (3) provide training programs through education and 
     training organizations jointly administered by health care 
     providers and health care labor organizations or other 
     organizations representing staff nurses and frontline health 
     care workers, working in collaboration with accredited 
     schools of nursing and academic institutions.
       (b) Grants.--Not later than 6 months after the date of the 
     enactment of this Act, the Secretary of Labor (referred to in 
     this section as the ``Secretary'') shall establish a 
     partnership grant program to award grants to eligible 
     entities to carry out comprehensive programs to provide 
     education to nurses and create a pipeline to nursing for 
     incumbent ancillary health care workers who wish to advance 
     their careers, and to otherwise carry out the purposes of 
     this section.
       (c) Eligibility.--To be eligible for a grant under this 
     section, an entity shall be--
       (1) a health care entity that is jointly administered by a 
     health care employer and a labor union representing the 
     health care employees of the employer and that carries out 
     activities using labor-management training funds as provided 
     for under section 302(c)(6) of the Labor Management Relations 
     Act, 1947 (29 U.S.C. 186(c)(6));
       (2) an entity that operates a training program that is 
     jointly administered by--
       (A) one or more health care providers or facilities, or a 
     trade association of health care providers; and
       (B) one or more organizations which represent the interests 
     of direct care health care workers or staff nurses and in 
     which the direct care health care workers or staff nurses 
     have direct input as to the leadership of the organization;
       (3) a State training partnership program that consists of 
     nonprofit organizations that include equal participation from 
     industry, including public or private employers, and labor 
     organizations including joint labor-management training 
     programs, and which may include representatives from local 
     governments, worker investment agency one-stop career 
     centers, community-based organizations, community colleges, 
     and accredited schools of nursing; or
       (4) a school of nursing (as defined in section 801 of the 
     Public Health Service Act (42 U.S.C. 296)).
       (d) Additional Requirements for Health Care Employer 
     Described in Subsection (c).--To be eligible for a grant 
     under this section, a health care employer described in 
     subsection (c) shall demonstrate that it--
       (1) has an established program within its facility to 
     encourage the retention of existing nurses;
       (2) provides wages and benefits to its nurses that are 
     competitive for its market or that have been collectively 
     bargained with a labor organization; and
       (3) supports programs funded under this section through 1 
     or more of the following:
       (A) The provision of paid leave time and continued health 
     coverage to incumbent health care workers to allow their 
     participation in nursing career ladder programs, including 
     certified nurse assistants, licensed practical nurses, 
     licensed vocational nurses, and registered nurses.
       (B) Contributions to a joint labor-management training fund 
     which administers the program involved.
       (C) The provision of paid release time, incentive 
     compensation, or continued health coverage to staff nurses 
     who desire to work full- or part-time in a faculty position.
       (D) The provision of paid release time for staff nurses to 
     enable them to obtain a bachelor of science in nursing 
     degree, other advanced nursing degrees, specialty training, 
     or certification program.
       (E) The payment of tuition assistance which is managed by a 
     joint labor-management training fund or other jointly 
     administered program.
       (e) Other Requirements.--
       (1) Matching requirement.--
       (A) In general.--The Secretary may not make a grant under 
     this section unless the applicant involved agrees, with 
     respect to the costs to be incurred by the applicant in 
     carrying out the program under the grant, to make available 
     non-Federal contributions (in cash or in kind under 
     subparagraph (B)) toward such costs in an amount equal to not 
     less than $1 for each $1 of Federal funds provided in the 
     grant. Such contributions may be made directly or through 
     donations from public or private entities, or may be provided 
     through the cash equivalent of paid release time provided to 
     incumbent worker students.
       (B) Determination of amount of non-federal contribution.--
     Non-Federal contributions required in subparagraph (A) may be 
     in cash or in kind (including paid release time), fairly 
     evaluated, including equipment or services (and excluding 
     indirect or overhead costs). Amounts provided by the Federal 
     Government, or services assisted or subsidized to any 
     significant extent by the Federal Government, may not be 
     included in determining the amount of such non-Federal 
     contributions.
       (2) Required collaboration.--Entities carrying out or 
     overseeing programs carried out with assistance provided 
     under this section shall demonstrate collaboration with 
     accredited schools of nursing which may include community 
     colleges and other academic institutions providing 
     associate's, bachelor's, or advanced nursing degree programs 
     or specialty training or certification programs.
       (f) Use of Funds.--Amounts awarded to an entity under a 
     grant under this section shall be used for the following:
       (1) To carry out programs that provide education and 
     training to establish nursing career ladders to educate 
     incumbent health care workers to become nurses (including 
     certified nurse assistants, licensed practical nurses, 
     licensed vocational nurses, and registered nurses). Such 
     programs shall include one or more of the following:
       (A) Preparing incumbent workers to return to the classroom 
     through English-as-a-second-language education, GED 
     education, precollege counseling, college preparation 
     classes, and support with entry level college classes that 
     are a prerequisite to nursing.
       (B) Providing tuition assistance with preference for 
     dedicated cohort classes in community colleges, universities, 
     and accredited schools of nursing with supportive services 
     including tutoring and counseling.
       (C) Providing assistance in preparing for and meeting all 
     nursing licensure tests and requirements.
       (D) Carrying out orientation and mentorship programs that 
     assist newly graduated nurses in adjusting to working at the 
     bedside to ensure their retention postgraduation, and ongoing 
     programs to support nurse retention.
       (E) Providing stipends for release time and continued 
     health care coverage to enable incumbent health care workers 
     to participate in these programs.
       (2) To carry out programs that assist nurses in obtaining 
     advanced degrees and completing specialty training or 
     certification programs and to establish incentives for nurses 
     to assume nurse faculty positions on a part-time or full-time 
     basis. Such programs shall include one or more of the 
     following:
       (A) Increasing the pool of nurses with advanced degrees who 
     are interested in teaching by funding programs that enable 
     incumbent nurses to return to school.
       (B) Establishing incentives for advanced degree bedside 
     nurses who wish to teach in nursing programs so they can 
     obtain a leave from their bedside position to assume a full- 
     or part-time position as adjunct or full-time faculty without 
     the loss of salary or benefits.
       (C) Collaboration with accredited schools of nursing which 
     may include community colleges and other academic 
     institutions providing associate's, bachelor's, or advanced 
     nursing degree programs, or specialty training or 
     certification programs, for nurses to carry out innovative 
     nursing programs which meet the needs of bedside nursing and 
     health care providers.
       (g) Preference.--In awarding grants under this section the 
     Secretary shall give preference to programs that--
       (1) provide for improving nurse retention;
       (2) provide for improving the diversity of the new nurse 
     graduates to reflect changes in the demographics of the 
     patient population;

[[Page 27364]]

       (3) provide for improving the quality of nursing education 
     to improve patient care and safety;
       (4) have demonstrated success in upgrading incumbent health 
     care workers to become nurses or which have established 
     effective programs or pilots to increase nurse faculty; or
       (5) are modeled after or affiliated with such programs 
     described in paragraph (4).
       (h) Evaluation.--
       (1) Program evaluations.--An entity that receives a grant 
     under this section shall annually evaluate, and submit to the 
     Secretary a report on, the activities carried out under the 
     grant and the outcomes of such activities. Such outcomes may 
     include--
       (A) an increased number of incumbent workers entering an 
     accredited school of nursing and in the pipeline for nursing 
     programs;
       (B) an increasing number of graduating nurses and improved 
     nurse graduation and licensure rates;
       (C) improved nurse retention;
       (D) an increase in the number of staff nurses at the health 
     care facility involved;
       (E) an increase in the number of nurses with advanced 
     degrees in nursing;
       (F) an increase in the number of nurse faculty;
       (G) improved measures of patient quality (which may include 
     staffing ratios of nurses, patient satisfaction rates, and 
     patient safety measures); and
       (H) an increase in the diversity of new nurse graduates 
     relative to the patient population.
       (2) General report.--Not later than 2 years after the date 
     of the enactment of this Act, and annually thereafter, the 
     Secretary of Labor shall, using data and information from the 
     reports received under paragraph (1), submit to the Congress 
     a report concerning the overall effectiveness of the grant 
     program carried out under this section.
       (i) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section such sums as may 
     be necessary for each of fiscal years 2011 through 2015.

     SEC. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING.

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

           ``Subpart 3--Mental and Behavioral Health Training

     ``SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING PROGRAM.

       ``(a) Program.--The Secretary, acting through the 
     Administrator of the Health Resources and Services 
     Administration and in consultation with the Administrator of 
     the Substance Abuse and Mental Health Services 
     Administration, shall establish an interdisciplinary mental 
     and behavioral health training program consisting of awarding 
     grants and contracts under subsection (b).
       ``(b) Support and Development of Mental and Behavioral 
     Health Training Programs.--The Secretary shall make grants 
     to, or enter into contracts with, eligible entities--
       ``(1) to plan, develop, operate, or participate in an 
     accredited professional training program for mental and 
     behavioral health professionals to promote--
       ``(A) interdisciplinary training; and
       ``(B) coordination of the delivery of health care within 
     and across settings, including health care institutions, 
     community-based settings, and the patient's home;
       ``(2) to provide financial assistance to mental and 
     behavioral health professionals, who are participants in any 
     such program, and who plan to work in the field of mental and 
     behavioral health;
       ``(3) to plan, develop, operate, or participate in an 
     accredited program for the training of mental and behavioral 
     health professionals who plan to teach in the field of mental 
     and behavioral health; and
       ``(4) to provide financial assistance in the form of 
     traineeships and fellowships to mental and behavioral health 
     professionals who are participants in any such program and 
     who plan to teach in the field of mental and behavioral 
     health.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under subsection (b), an entity shall be--
       ``(1) an accredited health professions school, including an 
     accredited school or program of psychology, psychiatry, 
     social work, marriage and family therapy, professional mental 
     health or substance abuse counseling, or addiction medicine;
       ``(2) an accredited public or nonprofit private hospital;
       ``(3) a public or private nonprofit entity; or
       ``(4) a consortium of 2 or more entities described in 
     paragraphs (1) through (3).
       ``(d) Preference.--In awarding grants or contracts under 
     this section, the Secretary shall give preference to entities 
     that have a demonstrated record of at least one of the 
     following:
       ``(1) Training a high or significantly improved percentage 
     of health professionals who serve in underserved communities.
       ``(2) Supporting teaching programs that address the health 
     care needs of vulnerable populations.
       ``(3) Training individuals who are from disadvantaged 
     backgrounds (including racial and ethnic minorities 
     underrepresented among mental and behavioral health 
     professionals).
       ``(4) Training individuals who serve geriatric populations 
     with an emphasis on underserved elderly.
       ``(5) Training individuals who serve pediatric populations 
     with an emphasis on underserved children.
       ``(e) Report.--The Secretary shall submit to the Congress 
     an annual report on the program under this section.
       ``(f) Definition.--In this section:
       ``(1) The term `interdisciplinary' means collaboration 
     across health professions, specialties, and subspecialties, 
     which may include public health, nursing, allied health, 
     dietetics or nutrition, and appropriate health specialties.
       ``(2) The term `mental and behavioral health professional' 
     means an individual training or practicing--
       ``(A) in psychology; general, geriatric, child or 
     adolescent psychiatry; social work; marriage and family 
     therapy; professional mental health or substance abuse 
     counseling; or addiction medicine; or
       ``(B) another mental and behavioral health specialty, as 
     deemed appropriate by the Secretary.
       ``(g) Authorization of Appropriations.--To carry out this 
     section, there is authorized to be appropriated $60,000,000 
     for each of fiscal years 2011 through 2015. Of the amounts 
     appropriated to carry out this section for a fiscal year, not 
     less than 15 percent shall be used for training programs in 
     psychology.''.

     SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELEMEDICINE 
                   GRANT PROGRAMS.

       (a) Telehealth Network and Telehealth Resource Centers 
     Grant Programs.--Section 330I (42 U.S.C. 254c-14) is 
     amended--
       (1) in subsection (a)--
       (A) by striking paragraph (3) (relating to frontier 
     communities); and
       (B) by inserting after paragraph (2) the following:
       ``(3) Health disparities.--The term `health disparities' 
     has the meaning given such term in section 3171.'';
       (2) in subsection (d)(1)--
       (A) in subparagraph (B), by striking ``and'' at the end;
       (B) in subparagraph (C), by striking the period at the end 
     and inserting ``; and''; and
       (C) by adding at the end the following:
       ``(D) reduce health disparities.'';
       (3) in subsection (f)(1)(B)(iii)--
       (A) in subclause (VII), by inserting ``, including skilled 
     nursing facilities'' before the period at the end;
       (B) in subclause (IX), by inserting ``, including county 
     mental health and public mental health facilities'' before 
     the period at the end; and
       (C) by adding at the end the following:

       ``(XIII) Renal dialysis facilities.'';

       (4) by amending subsection (i) to read as follows:
       ``(i) Preferences.--
       ``(1) Telehealth networks.--In awarding grants under 
     subsection (d)(1) for projects involving telehealth networks, 
     the Secretary shall give preference to eligible entities 
     meeting at least one of the following:
       ``(A) Network.--The eligible entity is a health care 
     provider in, or proposing to form, a health care network that 
     furnishes services in a medically underserved area or a 
     health professional shortage area.
       ``(B) Broad geographic coverage.--The eligible entity 
     demonstrates broad geographic coverage in the rural or 
     medically underserved areas of the State or States in which 
     the entity is located.
       ``(C) Health disparities.--The eligible entity demonstrates 
     how the project to be funded through the grant will address 
     health disparities.
       ``(D) Linkages.--The eligible entity agrees to use the 
     grant to establish or develop plans for telehealth systems 
     that will link rural hospitals and rural health care 
     providers to other hospitals, health care providers, and 
     patients.
       ``(E) Efficiency.--The eligible entity agrees to use the 
     grant to promote greater efficiency in the use of health care 
     resources.
       ``(F) Viability.--The eligible entity demonstrates the 
     long-term viability of projects through--
       ``(i) availability of non-Federal funding sources; or
       ``(ii) institutional and community support for the 
     telehealth network.
       ``(G) Services.--The eligible entity provides a plan for 
     coordinating system use by eligible entities and prioritizes 
     use of grant funds for health care services over nonclinical 
     uses.
       ``(2) Telehealth resource centers.--In awarding grants 
     under subsection (d)(2) for projects involving telehealth 
     resource centers, the Secretary shall give preference to 
     eligible entities meeting at least one of the following:
       ``(A) Provision of a broad range of services.--The eligible 
     entity has a record of success in the provision of a broad 
     range of telehealth services to medically underserved areas 
     or populations.
       ``(B) Provision of telehealth technical assistance.--The 
     eligible entity has a record of success in the provision of 
     technical assistance to providers serving medically 
     underserved communities or populations in the

[[Page 27365]]

     establishment and implementation of telehealth services.
       ``(C) Collaboration and sharing of expertise.--The eligible 
     entity has a demonstrated record of collaborating and sharing 
     expertise with providers of telehealth services at the 
     national, regional, State, and local levels.'';
       (5) in subsection (j)(2)(B), by striking ``such projects 
     for fiscal year 2001'' and all that follows through the 
     period and inserting ``such projects for fiscal year 2010.'';
       (6) in subsection (k)(1)--
       (A) in subparagraph (E)(i), by striking ``transmission of 
     medical data'' and inserting ``transmission and electronic 
     archival of medical data''; and
       (B) by amending subparagraph (F) to read as follows:
       ``(F) developing projects to use telehealth technology to--
       ``(i) facilitate collaboration between health care 
     providers;
       ``(ii) promote telenursing services; or
       ``(iii) promote patient understanding and adherence to 
     national guidelines for chronic disease and self-management 
     of such conditions;'';
       (7) in subsection (q), by striking ``Not later than 
     September 30, 2005'' and inserting ``Not later than 1 year 
     after the date of the enactment of the Affordable Health Care 
     for America Act, and annually thereafter'';
       (8) by striking subsection (r);
       (9) by redesignating subsection (s) as subsection (r); and
       (10) in subsection (r) (as so redesignated)--
       (A) in paragraph (1)--
       (i) by striking ``and'' before ``such sums''; and
       (ii) by inserting ``, $10,000,000 for fiscal year 2011, and 
     such sums as may be necessary for each of fiscal years 2012 
     through 2015'' before the semicolon; and
       (B) in paragraph (2)--
       (i) by striking ``and'' before ``such sums''; and
       (ii) by inserting ``, $10,000,000 for fiscal year 2011, and 
     such sums as may be necessary for each of fiscal years 2012 
     through 2015'' before the period.
       (b) Telemedicine; Incentive Grants Regarding Coordination 
     Among States.--Subsection (b) of section 330L (42 U.S.C. 
     254c-18) is amended by inserting ``, $10,000,000 for fiscal 
     year 2011, and such sums as may be necessary for each of 
     fiscal years 2012 through 2015'' before the period at the 
     end.

     SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLUENZA: 
                   DEMONSTRATION PROGRAM USING ELEMENTARY AND 
                   SECONDARY SCHOOLS AS INFLUENZA VACCINATION 
                   CENTERS.

       (a) Purpose.--The Secretary of Health and Human Services in 
     consultation with the Secretary of Education, shall award 
     grants to eligible partnerships to carry out demonstration 
     programs designed to test the feasibility of using the 
     Nation's elementary schools and secondary schools as 
     influenza vaccination centers.
       (b) In General.--The Secretary shall coordinate with the 
     Secretary of Labor, the Secretary of Education, State 
     Medicaid agencies, State insurance agencies, and private 
     insurers to carry out a program consisting of awarding grants 
     under subsection (c) to ensure that children have coverage 
     for all reasonable and customary expenses related to 
     influenza vaccinations, including the costs of purchasing and 
     administering the vaccine incurred when influenza vaccine is 
     administered outside of the physician's office in a school or 
     other related setting.
       (c) Program Description.--
       (1) Grants.--From amounts appropriated pursuant to 
     subsection (l), the Secretary shall award grants to eligible 
     partnerships to be used to provide influenza vaccinations to 
     children in elementary and secondary schools, in coordination 
     with school nurses, school health care programs, community 
     health care providers, State insurance agencies, or private 
     insurers.
       (2) ACIP recommendations.--The program under this section 
     shall be designed to administer vaccines consistent with the 
     recommendations of the Centers for Disease Control and 
     Prevention's Advisory Committee on Immunization Practices 
     (ACIP) for the annual vaccination of all children 5 through 
     19 years of age.
       (3) Participation voluntary.--Participation by a school or 
     an individual shall be voluntary.
       (d) Use of Funds.--Eligible partnerships receiving a grant 
     under this section shall ensure the maximum number of 
     children access influenza vaccinations as follows:
       (1) Covered children.--To the extent to which payment of 
     the costs of purchasing or administering the influenza 
     vaccine for children is not covered through other federally 
     funded programs or through private insurance, eligible 
     partnerships receiving a grant shall use funds to purchase 
     and administer influenza vaccinations.
       (2) Children covered by other federal programs.--For 
     children who are eligible under other federally funded 
     programs for payment of the costs of purchasing or 
     administering the influenza vaccine, eligible partnerships 
     receiving a grant shall not use funds provided under this 
     section for such costs.
       (3) Children covered by private health insurance.--For 
     children who have private insurance, eligible partnerships 
     receiving a grant shall offer assistance in accessing 
     coverage for vaccinations administered through the program 
     under this section.
       (e) Privacy.--The Secretary shall ensure that the program 
     under this section adheres to confidentiality and privacy 
     requirements of section 264 of the Health Insurance 
     Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2 
     note) and section 444 of the General Education Provisions Act 
     (20 U.S.C. 1232g; commonly referred to as the ``Family 
     Educational Rights and Privacy Act of 1974'').
       (f) Application.--An eligible partnership desiring a grant 
     under this section shall submit an application to the 
     Secretary at such time, in such manner, and containing such 
     information as the Secretary may require.
       (g) Duration.--Eligible partnerships receiving a grant 
     shall administer a demonstration program funded through this 
     section over a period of 2 consecutive school years.
       (h) Choice of Vaccine.--The program under this section 
     shall not restrict the discretion of a health care provider 
     to administer any influenza vaccine approved by the Food and 
     Drug Administration for use in pediatric populations.
       (i) Awards.--The Secretary shall award--
       (1) a minimum of 10 grants in 10 different States to 
     eligible partnerships that each include one or more public 
     schools serving primarily low-income students; and
       (2) a minimum of 5 grants in 5 different States to eligible 
     partnerships that each include one or more public schools 
     located in a rural local educational agency.
       (j) Report.--Not later than 90 days following the 
     completion of the program under this section, the Secretary 
     shall submit to the Committees on Education and Labor, Energy 
     and Commerce, and Appropriations of the House of 
     Representatives and to the Committees on Health, Education, 
     Labor, and Pensions and Appropriations of the Senate a report 
     on the results of the program. The report shall include--
       (1) an assessment of the influenza vaccination rates of 
     school-age children in localities where the program is 
     implemented, compared to the national average influenza 
     vaccination rates for school-aged children, including whether 
     school-based vaccination assists in achieving the 
     recommendations of the Advisory Committee on Immunization 
     Practices;
       (2) an assessment of the utility of employing elementary 
     schools and secondary schools as a part of a multistate, 
     community-based pandemic response program that is consistent 
     with existing Federal and State pandemic response plans;
       (3) an assessment of the feasibility of using existing 
     Federal and private insurance funding in establishing a 
     multistate, school-based vaccination program for seasonal 
     influenza vaccination;
       (4) an assessment of the number of education days gained by 
     students as a result of seasonal vaccinations based on 
     absenteeism rates;
       (5) a determination of whether the program under this 
     section--
       (A) increased vaccination rates in the participating 
     localities; and
       (B) was implemented for sufficient time for gathering 
     enough valid data; and
       (6) a recommendation on whether the program should be 
     continued, expanded, or terminated.
       (k) Definitions.--In this section:
       (1) Eligible partnership.--The term ``eligible 
     partnership'' means a local public health department, or 
     another health organization defined by the Secretary as 
     eligible to submit an application, and one or more elementary 
     and secondary schools.
       (2) Elementary school.--The terms ``elementary school'' and 
     ``secondary school'' have the meanings given such terms in 
     section 9101 of the Elementary and Secondary Education Act of 
     1965 (20 U.S.C. 7801).
       (3) Low-income.--The term ``low-income'' means a student, 
     age 5 through 19, eligible for free or reduced-price lunch 
     under the National School Lunch Act (42 U.S.C. 1751 et seq.).
       (4) Rural local educational agency.--The term ``rural local 
     educational agency'' means an eligible local educational 
     agency described in section 6211(b)(1) of the Elementary and 
     Secondary Education Act of 1965 (20 U.S.C. 7345(b)(1)).
       (5) Secretary.--Except as otherwise specified, the term 
     ``Secretary'' means the Secretary of Health and Human 
     Services.
       (l) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

     SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM.

       Section 1509 of the Public Health Service Act (42 U.S.C. 
     300n-4a) is amended--
       (1) in subsection (a)--
       (A) by striking the heading and inserting ``In General.--
     ''; and
       (B) in the matter preceding paragraph (1), by striking 
     ``may make grants'' and all that follows through ``purpose'' 
     and inserting the following: ``may make grants to such States 
     for the purpose''; and
       (2) in subsection (d)(1), by striking ``there are 
     authorized'' and all that follows through

[[Page 27366]]

     the period and inserting ``there are authorized to be 
     appropriated $70,000,000 for fiscal year 2011, $73,500,000 
     for fiscal year 2012, $77,000,000 for fiscal year 2013, 
     $81,000,000 for fiscal year 2014, and $85,000,000 for fiscal 
     year 2015.''.

     SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.

       Part B of title III (42 U.S.C. 243 et seq.) is amended by 
     inserting after section 317T the following:

     ``SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN 
                   PREGNANCY.

       ``(a) Program.--To the extent and in the amount of 
     appropriations made in advance in appropriations Acts, the 
     Secretary, acting through the Director of the Centers for 
     Disease Control and Prevention, shall establish a program 
     consisting of making grants, in amounts determined under 
     subsection (c), to each State that submits an application in 
     accordance with subsection (d) for an evidence-based 
     education program described in subsection (b).
       ``(b) Use of Funds.--Amounts received by a State under this 
     section shall be used to conduct or support evidence-based 
     education programs (directly or through grants or contracts 
     to public or private nonprofit entities, including schools 
     and community-based and faith-based organizations) to reduce 
     teen pregnancy or sexually transmitted diseases.
       ``(c) Distribution of Funds.--The Director shall, for 
     fiscal year 2011 and each subsequent fiscal year, make a 
     grant to each State described in subsection (a) in an amount 
     equal to the product of--
       ``(1) the amount appropriated to carry out this section for 
     the fiscal year; and
       ``(2) the percentage determined for the State under section 
     502(c)(1)(B)(ii) of the Social Security Act.
       ``(d) Application.--To seek a grant under this section, a 
     State shall submit an application at such time, in such 
     manner, and containing such information and assurance of 
     compliance with this section as the Secretary may require. At 
     a minimum, an application shall to the satisfaction of the 
     Secretary--
       ``(1) describe how the State's proposal will address the 
     needs of at-risk teens in the State;
       ``(2) identify the evidence-based education program or 
     programs selected from the registry developed under 
     subsection (g) that will be used to address risks in priority 
     populations;
       ``(3) describe how the program or programs will be 
     implemented and any adaptations to the evidence-based model 
     that will be made;
       ``(4) list any private and public entities with whom the 
     State proposes to work, including schools and community-based 
     and faith-based organizations, and demonstrate their capacity 
     to implement the proposed program or programs; and
       ``(5) identify an independent entity that will evaluate the 
     impact of the program or programs.
       ``(e) Evaluation.--
       ``(1) Requirement.--As a condition on receipt of a grant 
     under this section, a State shall agree--
       ``(A) to arrange for an independent evaluation of the 
     impact of the programs to be conducted or supported through 
     the grant; and
       ``(B) submit reports to the Secretary on such programs and 
     the results of evaluation of such programs.
       ``(2) Funding limitation.--Of the amounts made available to 
     a State through a grant under this section for any fiscal 
     year, not more than 10 percent may be used for such 
     evaluation.
       ``(f) Rule of Construction.--This section shall not be 
     construed to preempt or limit any State law regarding 
     parental involvement and decisionmaking in children's 
     education.
       ``(g) Registry of Eligible Programs.--The Secretary shall 
     develop not later than 180 days after the date of the 
     enactment of the Affordable Health Care for America Act, and 
     periodically update thereafter, a publicly available registry 
     of programs described in subsection (b) that, as determined 
     by the Secretary--
       ``(1) meet the definition of the term `evidence-based' in 
     subsection (i);
       ``(2) are medically and scientifically accurate; and
       ``(3) provide age-appropriate information.
       ``(h) Matching Funds.--The Secretary may award a grant to a 
     State under this section for a fiscal year only if the State 
     agrees to provide, from non-Federal sources, an amount equal 
     to $1 (in cash or in kind) for each $4 provided through the 
     grant to carry out the activities supported by the grant.
       ``(i) Definition.--In this section, the term `evidence-
     based' means based on a model that has been found, in 
     methodologically sound research--
       ``(1) to delay initiation of sex;
       ``(2) to decrease number of partners;
       ``(3) to reduce teen pregnancy;
       ``(4) to reduce sexually transmitted infection rates; or
       ``(5) to improve rates of contraceptive use.
       ``(j) Authorization of Appropriations.--To carry out this 
     section, there is authorized to be appropriated $50,000,000 
     for each of fiscal years 2011 through 2015.''.

     SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM SPECTRUM 
                   DISORDERS.

       Title I of the Developmental Disabilities Assistance and 
     Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) is 
     amended by adding at the end the following:

``Subtitle F--National Training Initiative on Autism Spectrum Disorders

     ``SEC. 171. NATIONAL TRAINING INITIATIVE.

       ``(a) Grants and Technical Assistance.--
       ``(1) Grants.--
       ``(A) In general.--The Secretary, in consultation with the 
     Interagency Autism Coordinating Committee, shall award 
     multiyear grants to eligible entities to provide individuals 
     (including parents and health, allied health, vocational, and 
     educational professionals) with interdisciplinary training, 
     continuing education, technical assistance, and information 
     for the purpose of improving services rendered to children 
     and adults with autism, and their families, to address unmet 
     needs related to autism.
       ``(B) Eligible entity.--To be eligible to receive a grant 
     under this subsection, an entity shall be--
       ``(i) a University Center for Excellence in Developmental 
     Disabilities Education, Research, and Service; or
       ``(ii) a comparable interdisciplinary education, research, 
     and service entity.
       ``(C) Application requirements.--An entity that desires to 
     receive a grant for a program under this paragraph shall 
     submit to the Secretary an application--
       ``(i) demonstrating that the entity has capacity to--

       ``(I) provide training and technical assistance in 
     evidence-based practices to evaluate, and provide effective 
     interventions, services, treatments, and supports to, 
     children and adults with autism and their families;
       ``(II) include individuals with autism and their families 
     as part of the program to ensure that an individual- and 
     family-centered approach is used;
       ``(III) share and disseminate materials and practices that 
     are developed for, and evaluated to be effective in, the 
     provision of training and technical assistance; and
       ``(IV) provide training, technical assistance, 
     interventions, services, treatments, and supports under this 
     subsection statewide.

       ``(ii) providing assurances that the entity will--

       ``(I) provide trainees under this subsection with an 
     appropriate balance of interdisciplinary academic and 
     community-based experiences; and
       ``(II) provide to the Secretary, in the manner prescribed 
     by the Secretary, data regarding the number of individuals 
     who have benefitted from, and outcomes of, the provision of 
     training and technical assistance under this subsection;

       ``(iii) providing assurances that training, technical 
     assistance, dissemination of information, and services under 
     this subsection will be--

       ``(I) consistent with the goals of this Act, the Americans 
     with Disabilities Act of 1990, the Individuals with 
     Disabilities Education Act, and the Elementary and Secondary 
     Education Act of 1965; and
       ``(II) conducted in coordination with relevant State 
     agencies, institutions of higher education, and service 
     providers; and

       ``(iv) containing such other information and assurances as 
     the Secretary may require.
       ``(D) Use of funds.--A grant received under this subsection 
     shall be used to provide individuals (including parents and 
     health, allied health, vocational, and educational 
     professionals) with interdisciplinary training, continuing 
     education, technical assistance, and information for the 
     purpose of improving services rendered to children and adults 
     with autism, and their families, to address unmet needs 
     related to autism. Such training, education, assistance, and 
     information shall include each of the following:
       ``(i) Training health, allied health, vocational, and 
     educational professionals to identify, evaluate the needs of, 
     and develop interventions, services, treatments, and supports 
     for, children and adults with autism.
       ``(ii) Developing model services and supports that 
     demonstrate evidence-based practices.
       ``(iii) Developing systems and products that allow for the 
     interventions, services, treatments, and supports to be 
     evaluated for fidelity of implementation.
       ``(iv) Working to expand the availability of evidence-
     based, lifelong interventions; educational, employment, and 
     transition services; and community supports.
       ``(v) Providing statewide technical assistance in 
     collaboration with relevant State agencies, institutions of 
     higher education, autism advocacy groups, and community-based 
     service providers.
       ``(vi) Working to develop comprehensive systems of supports 
     and services for individuals with autism and their families, 
     including seamless transitions between education and health 
     systems across the lifespan.
       ``(vii) Promoting training, technical assistance, 
     dissemination of information, supports, and services.
       ``(viii) Developing mechanisms to provide training and 
     technical assistance, including for-credit courses, intensive 
     summer institutes, continuing education programs, distance 
     based programs, and Web-based information dissemination 
     strategies.
       ``(ix) Promoting activities that support community-based 
     family and individual

[[Page 27367]]

     services and enable individuals with autism and related 
     developmental disabilities to fully participate in society 
     and achieve good quality-of-life outcomes.
       ``(x) Collecting data on the outcomes of training and 
     technical assistance programs to meet statewide needs for the 
     expansion of services to children and adults with autism.
       ``(E) Amount of grants.--The amount of a grant to any 
     entity for a fiscal year under this section shall be not less 
     than $250,000.
       ``(2) Technical assistance.--The Secretary shall reserve 2 
     percent of the amount appropriated to carry out this 
     subsection for a fiscal year to make a grant to a national 
     organization with demonstrated capacity for providing 
     training and technical assistance to--
       ``(A) assist in national dissemination of specific 
     information, including evidence-based best practices, from 
     interdisciplinary training programs, and when appropriate, 
     other entities whose findings would inform the work performed 
     by entities awarded grants;
       ``(B) compile and disseminate strategies and materials that 
     prove to be effective in the provision of training and 
     technical assistance so that the entire network can benefit 
     from the models, materials, and practices developed in 
     individual centers;
       ``(C) assist in the coordination of activities of grantees 
     under this subsection;
       ``(D) develop a Web portal that will provide linkages to 
     each of the individual training initiatives and provide 
     access to training modules, promising training, and technical 
     assistance practices and other materials developed by 
     grantees;
       ``(E) serve as a research-based resource for Federal and 
     State policymakers on information concerning the provision of 
     training and technical assistance for the assessment, and 
     provision of supports and services for, children and adults 
     with autism;
       ``(F) convene experts from multiple interdisciplinary 
     training programs, individuals with autism, and the families 
     of such individuals to discuss and make recommendations with 
     regard to training issues related to assessment, 
     interventions, services, treatment, and supports for children 
     and adults with autism; and
       ``(G) undertake any other functions that the Secretary 
     determines to be appropriate.
       ``(3) Authorization of appropriations.--To carry out this 
     subsection, there are authorized to be appropriated 
     $17,000,000 for fiscal year 2011 and such sums as may be 
     necessary for each of fiscal years 2012 through 2015.
       ``(b) Expansion of the Number of University Centers for 
     Excellence in Developmental Disabilities Education, Research, 
     and Service.--
       ``(1) Grants.--To provide for the establishment of up to 4 
     new University Centers for Excellence in Developmental 
     Disabilities Education, Research, and Service, the Secretary 
     shall award up to 4 grants to institutions of higher 
     education.
       ``(2) Applicable provisions.--Except for subsection (a)(3), 
     the provisions of subsection (a) shall apply with respect to 
     grants under this subsection to the same extent and in the 
     same manner as such provisions apply with respect to grants 
     under subsection (a).
       ``(3) Priority.--In awarding grants under this subsection, 
     the Secretary shall give priority to applicants that--
       ``(A) are minority institutions that have demonstrated 
     capacity to meet the requirements of this section and provide 
     services to individuals with autism and their families; or
       ``(B) are located in a State with one or more underserved 
     populations.
       ``(4) Authorization of appropriations.--To carry out this 
     subsection, there is authorized to be appropriated $2,000,000 
     for each of fiscal years 2011 through 2015.
       ``(c) Definitions.--In this section:
       ``(1) The term `autism' means an autism spectrum disorder 
     or a related developmental disability.
       ``(2) The term `interventions' means educational methods 
     and positive behavioral support strategies designed to 
     improve or ameliorate symptoms associated with autism.
       ``(3) The term `minority institution' has the meaning given 
     to such term in section 365 of the Higher Education Act of 
     1965.
       ``(4) The term `services' means services to assist 
     individuals with autism to live more independently in their 
     communities.
       ``(5) The term `treatments' means health services, 
     including mental health services, designed to improve or 
     ameliorate symptoms associated with autism.
       ``(6) The term `University Center for Excellence in 
     Developmental Disabilities Education, Research, and Service' 
     means a University Center for Excellence in Development 
     Disabilities Education, Research, and Service that has been 
     or is funded through subtitle D or subsection (b).''.

     SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGEMENT SERVICES 
                   IN TREATMENT OF CHRONIC DISEASES.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary''), acting 
     through the Director of the Agency for Health Care Research 
     and Quality, shall establish a program to provide grants to 
     eligible entities to implement medication management services 
     (referred to in this section as ``MTM services'') provided by 
     licensed pharmacists, as a part of a collaborative, 
     multidisciplinary, interprofessional approach to the 
     treatment of chronic diseases for targeted individuals, to 
     improve the quality of care and reduce overall cost in the 
     treatment of such diseases. The Secretary shall commence the 
     grant program not later than May 1, 2011.
       (b) Eligible Entities.--To be eligible to receive a grant 
     under subsection (a), an entity shall--
       (1) provide a setting appropriate for MTM services, as 
     recommended by the experts described in subsection (e);
       (2) submit to the Secretary a plan for achieving long-term 
     financial sustainability;
       (3) where applicable, submit a plan for coordinating MTM 
     services with other local providers and where applicable, 
     through or in collaboration with the Medicare Medical Home 
     Pilot program as established by section 1866F of the Social 
     Security Act, as added by section 1302(a) of this Act;
       (4) submit a plan for meeting the requirements under 
     subsection (c); and
       (5) submit to the Secretary such other information as the 
     Secretary may require.
       (c) MTM Services to Targeted Individuals.--The MTM services 
     provided with the assistance of a grant awarded under 
     subsection (a) shall, as allowed by State law (including 
     applicable collaborative pharmacy practice agreements), 
     include--
       (1) performing or obtaining necessary assessments of the 
     health and functional status of each patient receiving such 
     MTM services;
       (2) formulating a medication treatment plan according to 
     therapeutic goals agreed upon by the prescriber and the 
     patient or caregiver or authorized representative of the 
     patient;
       (3) selecting, initiating, modifying, recommending changes 
     to, or administering medication therapy;
       (4) monitoring, which may include access to, ordering, or 
     performing laboratory assessments, and evaluating the 
     response of the patient to therapy, including safety and 
     effectiveness;
       (5) performing an initial comprehensive medication review 
     to identify, resolve, and prevent medication-related 
     problems, including adverse drug events, quarterly targeted 
     medication reviews for ongoing monitoring, and additional 
     followup interventions on a schedule developed 
     collaboratively with the prescriber;
       (6) documenting the care delivered and communicating 
     essential information about such care (including a summary of 
     the medication review) and the recommendations of the 
     pharmacist to other appropriate health care providers of the 
     patient in a timely fashion;
       (7) providing education and training designed to enhance 
     the understanding and appropriate use of the medications by 
     the patient, caregiver, and other authorized representative;
       (8) providing information, support services, and resources 
     and strategies designed to enhance patient adherence with 
     therapeutic regimens;
       (9) coordinating and integrating MTM services within the 
     broader health care management services provided to the 
     patient; and
       (10) such other patient care services as are allowed under 
     the scopes of practice for pharmacists for purposes of other 
     Federal programs.
       (d) Targeted Individuals.--MTM services provided by 
     licensed pharmacists under a grant awarded under subsection 
     (a) shall be offered to targeted individuals who--
       (1) take 4 or more prescribed medications (including over-
     the-counter and dietary supplements);
       (2) take any high-risk medications;
       (3) have 2 or more chronic diseases, as identified by the 
     Secretary; or
       (4) have undergone a transition of care, or other factors, 
     as determined by the Secretary, that are likely to create a 
     high risk of medication-related problems.
       (e) Consultation With Experts.--In designing and 
     implementing MTM services provided under grants awarded under 
     subsection (a), the Secretary shall consult with Federal, 
     State, private, public-private, and academic entities, 
     pharmacy and pharmacist organizations, health care 
     organizations, consumer advocates, chronic disease groups, 
     and other stakeholders involved with the research, 
     dissemination, and implementation of pharmacist-delivered MTM 
     services, as the Secretary determines appropriate. The 
     Secretary, in collaboration with this group, shall determine 
     whether it is possible to incorporate rapid cycle process 
     improvement concepts in use in other Federal programs that 
     have implemented MTM services.
       (f) Reporting to the Secretary.--An entity that receives a 
     grant under subsection (a) shall submit to the Secretary a 
     report that describes and evaluates, as requested by the 
     Secretary, the activities carried out under subsection (c), 
     including quality measures, as determined by the Secretary.
       (g) Evaluation and Report.--The Secretary shall submit to 
     the relevant committees of Congress a report which shall--
       (1) assess the clinical effectiveness of pharmacist-
     provided services under the MTM services program, as compared 
     to usual care, including an evaluation of whether enrollees

[[Page 27368]]

     maintained better health with fewer hospitalizations and 
     emergency room visits than similar patients not enrolled in 
     the program;
       (2) assess changes in overall health care resource of 
     targeted individuals;
       (3) assess patient and prescriber satisfaction with MTM 
     services;
       (4) assess the impact of patient-cost-sharing requirements 
     on medication adherence and recommendations for 
     modifications;
       (5) identify and evaluate other factors that may impact 
     clinical and economic outcomes, including demographic 
     characteristics, clinical characteristics, and health 
     services use of the patient, as well as characteristics of 
     the regimen, pharmacy benefit, and MTM services provided; and
       (6) evaluate the extent to which participating pharmacists 
     who maintain a dispensing role have a conflict of interest in 
     the provision of MTM services, and if such conflict is found, 
     provide recommendations on how such a conflict might be 
     appropriately addressed.
       (h) Grant To Fund Development of Performance Measures.--The 
     Secretary may award grants or contracts to eligible entities 
     for the purpose of funding the development of performance 
     measures that assess the use and effectiveness of medication 
     therapy management services.

     SEC. 2529. POSTPARTUM DEPRESSION.

       (a) Expansion and Intensification of Activities.--
       (1) Continuation of activities.--The Secretary is 
     encouraged to expand and intensify activities on postpartum 
     conditions.
       (2) Programs for postpartum conditions.--In carrying out 
     paragraph (1), the Secretary is encouraged to continue 
     research to expand the understanding of the causes of, and 
     treatments for, postpartum conditions, including conducting 
     and supporting the following:
       (A) Basic research concerning the etiology and causes of 
     the conditions.
       (B) Epidemiological studies to address the frequency and 
     natural history of the conditions and the differences among 
     racial and ethnic groups with respect to the conditions.
       (C) The development of improved screening and diagnostic 
     techniques.
       (D) Clinical research for the development and evaluation of 
     new treatments.
       (E) Information and education programs for health 
     professionals and the public, which may include a coordinated 
     national campaign that--
       (i) is designed to increase the awareness and knowledge of 
     postpartum conditions;
       (ii) may include public service announcements through 
     television, radio, and other means; and
       (iii) may focus on--

       (I) raising awareness about screening;
       (II) educating new mothers and their families about 
     postpartum conditions to promote earlier diagnosis and 
     treatment; and
       (III) ensuring that such education includes complete 
     information concerning postpartum conditions, including its 
     symptoms, methods of coping with the illness, and treatment 
     resources.

       (b) Report by the Secretary.--
       (1) Study.--The Secretary shall conduct a study on the 
     benefits of screening for postpartum conditions.
       (2) Report.--Not later than 2 years after the date of the 
     enactment of this Act, the Secretary shall complete the study 
     required by paragraph (1) and submit a report to the Congress 
     on the results of such study.
       (c) Sense of Congress Regarding Longitudinal Study of 
     Relative Mental Health Consequences for Women of Resolving a 
     Pregnancy.--
       (1) Sense of congress.--It is the sense of the Congress 
     that the Director of the National Institute of Mental Health 
     may conduct a nationally representative longitudinal study 
     (during the period of fiscal years 2011 through 2020) on the 
     relative mental health consequences for women of resolving a 
     pregnancy (intended and unintended) in various ways, 
     including carrying the pregnancy to term and parenting the 
     child, carrying the pregnancy to term and placing the child 
     for adoption, miscarriage, and having an abortion. This study 
     may assess the incidence, timing, magnitude, and duration of 
     the immediate and long-term mental health consequences 
     (positive or negative) of these pregnancy outcomes.
       (2) Report.--Beginning not later than 3 years after the 
     date of the enactment of this Act, and periodically 
     thereafter for the duration of the study, such Director may 
     prepare and submit to the Congress reports on the findings of 
     the study.
       (d) Definitions.--In this section:
       (1) The term ``postpartum condition'' means postpartum 
     depression or postpartum psychosis.
       (2) The term ``Secretary'' means the Secretary of Health 
     and Human Services.
       (e) Authorization of Appropriations.--For the purpose of 
     carrying out this section, in addition to any other amounts 
     authorized to be appropriated for such purpose, there are 
     authorized to be appropriated such sums as may be necessary 
     for each of fiscal years 2011 through 2013.

     SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND 
                   OUTCOMES.

       Part P of title III (42 U.S.C. 280g et seq.) is amended by 
     adding at the end the following:

     ``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND 
                   OUTCOMES.

       ``(a) Grants Authorized.--The Secretary, in collaboration 
     with the Director of the Centers for Disease Control and 
     Prevention and other Federal officials determined appropriate 
     by the Secretary, is authorized to award grants to eligible 
     entities to promote positive health behaviors for populations 
     in medically underserved communities through the use of 
     community health workers.
       ``(b) Use of Funds.--Grants awarded under subsection (a) 
     shall be used to support community health workers--
       ``(1) to educate, guide, and provide outreach in a 
     community setting regarding health problems prevalent in 
     medically underserved communities, especially racial and 
     ethnic minority populations;
       ``(2) to educate, guide, and provide experiential learning 
     opportunities that target behavioral risk factors including--
       ``(A) poor nutrition;
       ``(B) physical inactivity;
       ``(C) being overweight or obese;
       ``(D) tobacco use;
       ``(E) alcohol and substance use;
       ``(F) injury and violence;
       ``(G) risky sexual behavior;
       ``(H) untreated mental health problems;
       ``(I) untreated dental and oral health problems; and
       ``(J) understanding informed consent;
       ``(3) to educate and provide guidance regarding effective 
     strategies to promote positive health behaviors within the 
     family;
       ``(4) to educate and provide outreach regarding enrollment 
     in health insurance including the State Children's Health 
     Insurance Program under title XXI of the Social Security Act, 
     Medicare under title XVIII of such Act, and Medicaid under 
     title XIX of such Act;
       ``(5) to educate and refer underserved populations to 
     appropriate health care agencies and community-based programs 
     and organizations in order to increase access to quality 
     health care services, including preventive health services, 
     and to eliminate duplicative care; or
       ``(6) to educate, guide, and provide home visitation 
     services regarding maternal health and prenatal care.
       ``(c) Application.--
       ``(1) In general.--Each eligible entity that desires to 
     receive a grant under subsection (a) shall submit an 
     application to the Secretary, at such time, in such manner, 
     and accompanied by such information as the Secretary may 
     require.
       ``(2) Contents.--Each application submitted pursuant to 
     paragraph (1) shall--
       ``(A) describe the activities for which assistance is 
     sought under this section;
       ``(B) contain an assurance that, with respect to each 
     community health worker program receiving funds under the 
     grant, such program will provide training and supervision to 
     community health workers to enable such workers to provide 
     authorized program services;
       ``(C) contain an assurance that the applicant will evaluate 
     the effectiveness of community health worker programs 
     receiving funds under the grant;
       ``(D) contain an assurance that each community health 
     worker program receiving funds under the grant will provide 
     services in the cultural context most appropriate for the 
     individuals served by the program;
       ``(E) contain a plan to document and disseminate project 
     descriptions and results to other States and organizations as 
     identified by the Secretary; and
       ``(F) describe plans to enhance the capacity of individuals 
     to utilize health services and health-related social services 
     under Federal, State, and local programs by--
       ``(i) assisting individuals in establishing eligibility 
     under the programs and in receiving the services or other 
     benefits of the programs; and
       ``(ii) providing other services as the Secretary determines 
     to be appropriate, that may include transportation and 
     translation services.
       ``(d) Priority.--In awarding grants under subsection (a), 
     the Secretary shall give priority to applicants that--
       ``(1) propose to target geographic areas--
       ``(A) with a high percentage of residents who are eligible 
     for health insurance but are uninsured or underinsured;
       ``(B) with a high percentage of residents who suffer from 
     chronic diseases including pulmonary conditions, 
     hypertension, heart disease, mental disorders, diabetes, and 
     asthma; and
       ``(C) with a high infant mortality rate;
       ``(2) have experience in providing health or health-related 
     social services to individuals who are underserved with 
     respect to such services; and
       ``(3) have documented community activity and experience 
     with community health workers.
       ``(e) Collaboration With Academic Institutions.--The 
     Secretary shall encourage community health worker programs 
     receiving funds under this section to collaborate with 
     academic institutions, especially those that graduate a 
     disproportionate number of

[[Page 27369]]

     health and health care students from underrepresented racial 
     and ethnic minority backgrounds. Nothing in this section 
     shall be construed to require such collaboration.
       ``(f) Evidence-Based Interventions.--The Secretary shall 
     encourage community health worker programs receiving funding 
     under this section to implement an outcome-based payment 
     system that rewards community health workers for connecting 
     underserved populations with the most appropriate services at 
     the most appropriate time. Nothing in this section shall be 
     construed to require such payment.
       ``(g) Quality Assurance and Cost Effectiveness.--The 
     Secretary shall establish guidelines for assuring the quality 
     of the training and supervision of community health workers 
     under the programs funded under this section and for assuring 
     the cost-effectiveness of such programs.
       ``(h) Monitoring.--The Secretary shall monitor community 
     health worker programs identified in approved applications 
     under this section and shall determine whether such programs 
     are in compliance with the guidelines established under 
     subsection (g).
       ``(i) Technical Assistance.--The Secretary may provide 
     technical assistance to community health worker programs 
     identified in approved applications under this section with 
     respect to planning, developing, and operating programs under 
     the grant.
       ``(j) Report to Congress.--
       ``(1) In general.--Not later than 4 years after the date on 
     which the Secretary first awards grants under subsection (a), 
     the Secretary shall submit to Congress a report regarding the 
     grant project.
       ``(2) Contents.--The report required under paragraph (1) 
     shall include the following:
       ``(A) A description of the programs for which grant funds 
     were used.
       ``(B) The number of individuals served under such programs.
       ``(C) An evaluation of--
       ``(i) the effectiveness of such programs;
       ``(ii) the cost of such programs; and
       ``(iii) the impact of the programs on the health outcomes 
     of the community residents.
       ``(D) Recommendations for sustaining the community health 
     worker programs developed or assisted under this section.
       ``(E) Recommendations regarding training to enhance career 
     opportunities for community health workers.
       ``(k) Definitions.--In this section:
       ``(1) Community health worker.--The term `community health 
     worker' means an individual who promotes health or nutrition 
     within the community in which the individual resides--
       ``(A) by serving as a liaison between communities and 
     health care agencies;
       ``(B) by providing guidance and social assistance to 
     community residents;
       ``(C) by enhancing community residents' ability to 
     effectively communicate with health care providers;
       ``(D) by providing culturally and linguistically 
     appropriate health or nutrition education;
       ``(E) by advocating for individual and community health, 
     including oral and mental, or nutrition needs; and
       ``(F) by providing referral and followup services or 
     otherwise coordinating care.
       ``(2) Community setting.--The term `community setting' 
     means a home or a community organization located in the 
     neighborhood in which a participant resides.
       ``(3) Medically underserved community.--The term `medically 
     underserved community' means a community identified by a 
     State, United States territory or possession, or federally 
     recognized Indian tribe--
       ``(A) that has a substantial number of individuals who are 
     members of a medically underserved population, as defined by 
     section 330(b)(3); and
       ``(B) a significant portion of which is a health 
     professional shortage area as designated under section 332.
       ``(4) Support.--The term `support' means the provision of 
     training, supervision, and materials needed to effectively 
     deliver the services described in subsection (b), 
     reimbursement for services, and other benefits.
       ``(5) Eligible entity.--The term `eligible entity' means a 
     public or private nonprofit entity (including a State or 
     public subdivision of a State, a public health department, or 
     a federally qualified health center), or a consortium of any 
     of such entities, located in the United States or territory 
     thereof.
       ``(l) Authorization of Appropriations.--There is authorized 
     to be appropriated to carry out this section $30,000,000 for 
     each of fiscal years 2011 through 2015.''.

     SEC. 2531. MEDICAL LIABILITY ALTERNATIVES.

       (a) Incentive Payments for Medical Liability Reform.--
       (1) In general.--To the extent and in the amounts made 
     available in advance in appropriations Acts, the Secretary 
     shall make an incentive payment, in an amount determined by 
     the Secretary, to each State that has an alternative medical 
     liability law in compliance with this section.
       (2) Determination by secretary.--The Secretary shall 
     determine that a State has an alternative medical liability 
     law in compliance with this section if the Secretary is 
     satisfied that--
       (A) the State enacted the law after the date of the 
     enactment of this Act and is implementing the law;
       (B) the law is effective; and
       (C) the contents of the law are in accordance with 
     paragraph (4).
       (3) Considerations for determining effectiveness.--In 
     determining whether an alternative medical liability law is 
     effective under paragraph (2)(B), the Secretary shall 
     consider whether the law--
       (A) makes the medical liability system more reliable 
     through prevention of, or prompt and fair resolution of, 
     disputes;
       (B) encourages the disclosure of health care errors; and
       (C) maintains access to affordable liability insurance.
       (4) Contents of alternative medical liability law.--The 
     contents of an alternative liability law are in accordance 
     with this paragraph if--
       (A) the litigation alternatives contained in the law 
     consist of certificate of merit, early offer, or both; and
       (B) the law does not limit attorneys' fees or impose caps 
     on damages.
       (5) No limitation on other state laws.--Nothing in this 
     section shall be construed to--
       (A) preempt or modify the application of any existing State 
     law that limits attorneys' fees or imposes caps on damages;
       (B) impair the authority of a State to establish or 
     implement a law limiting attorneys' fees or imposing caps on 
     damages; or
       (C) restrict the eligibility of a State for an incentive 
     payment under this section on the basis of a law described in 
     subparagraph (A) or (B) so long as any such law is not 
     established or implemented as part of the law described in 
     paragraph (4), as determined by the Secretary.
       (b) Use of Incentive Payments.--Amounts received by a State 
     as an incentive payment under this section shall be used to 
     improve health care in that State.
       (c) Technical Assistance.--The Secretary may provide 
     technical assistance to the States applying for or receiving 
     an incentive payment under this section.
       (d) Reports.--Beginning not later than one year after the 
     date of the enactment of this Act, the Secretary shall submit 
     to the Congress an annual report on the progress States have 
     made in enacting and implementing alternative medical 
     liability laws in compliance with this section. Such reports 
     shall contain sufficient documentation regarding the 
     effectiveness of such laws to enable an objective comparative 
     analysis of such laws.
       (e) Definition.--In this section--
       (1) the term ``Secretary'' means the Secretary of Health 
     and Human Services; and
       (2) the term ``State'' includes the several States, 
     District of Columbia, the Commonwealth of Puerto Rico, and 
     each other territory or possession of the United States.
       (f) Authorization of Appropriations.--There are authorized 
     to be appropriated to carry out this section such sums as may 
     be necessary, to remain available until expended.

     SEC. 2532. INFANT MORTALITY PILOT PROGRAMS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary''), acting 
     through the Director, shall award grants to eligible entities 
     to create, implement, and oversee infant mortality pilot 
     programs.
       (b) Period of a Grant.--The period of a grant under this 
     section shall be 5 consecutive fiscal years.
       (c) Preference.--In awarding grants under this section, the 
     Secretary shall give preference to eligible entities 
     proposing to serve any of the 15 counties or groups of 
     counties with the highest rates of infant mortality in the 
     United States in the past 3 years.
       (d) Use of Funds.--Any infant mortality pilot program 
     funded under this section may--
       (1) include the development of a plan that identifies the 
     individual needs of each community to be served and 
     strategies to address those needs;
       (2) provide outreach to at-risk mothers through programs 
     deemed appropriate by the Director;
       (3) develop and implement standardized systems for improved 
     access, utilization, and quality of social, educational, and 
     clinical services to promote healthy pregnancies, full term 
     births, and healthy infancies delivered to women and their 
     infants, such as--
       (A) counseling on infant care, feeding, and parenting;
       (B) postpartum care;
       (C) prevention of premature delivery; and
       (D) additional counseling for at-risk mothers, including 
     smoking cessation programs, drug treatment programs, alcohol 
     treatment programs, nutrition and physical activity programs, 
     postpartum depression and domestic violence programs, social 
     and psychological services, dental care, and parenting 
     programs;
       (4) establish a rural outreach program to provide care to 
     at-risk mothers in rural areas;
       (5) establish a regional public education campaign, 
     including a campaign to--
       (A) prevent preterm births; and
       (B) educate the public about infant mortality; and
       (6) provide for any other activities, programs, or 
     strategies as identified by the community plan.

[[Page 27370]]

       (e) Limitation.--Of the funds received through a grant 
     under this section for a fiscal year, an eligible entity 
     shall not use more than 10 percent for program evaluation.
       (f) Reports on Pilot Programs.--
       (1) In general.--Not later than 1 year after receiving a 
     grant, and annually thereafter for the duration of the grant 
     period, each entity that receives a grant under subsection 
     (a) shall submit a report to the Secretary detailing its 
     infant mortality pilot program.
       (2) Contents of report.--The reports required under 
     paragraph (1) shall include information such as the 
     methodology of, and outcomes and statistics from, the 
     grantee's infant mortality pilot program.
       (3) Evaluation.--The Secretary shall use the reports 
     required under paragraph (1) to evaluate, and conduct 
     statistical research on, infant mortality pilot programs 
     funded through this section.
       (g) Definitions.--For the purposes of this section:
       (1) Director.--The term ``Director'' means the Director of 
     the Centers for Disease Control and Prevention.
       (2) Eligible entity.--The term ``eligible entity'' means a 
     State, county, city, territorial, or tribal health department 
     that has submitted a proposal to the Secretary that the 
     Secretary deems likely to reduce infant mortality rates 
     within the standard metropolitan statistical area involved.
       (3) Tribal.--The term ``tribal'' refers to an Indian tribe, 
     a Tribal organization, or an Urban Indian organization, as 
     such terms are defined in section 4 of the Indian Health Care 
     Improvement Act.
       (h) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated $10,000,000 
     for each of fiscal years 2011 through 2015.

     SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAINING PROGRAM.

        (a) Program.--The Secretary of Health and Human Services, 
     acting through the Administrator of the Health Resources and 
     Services Administration, and in consultation with the 
     Secretary of Education, may establish a health sciences 
     training program consisting of awarding grants and contracts 
     under subsection (b) to prepare secondary school students for 
     careers in health professions.
       (b) Development and Implementation of Health Sciences 
     Curricula.--The Secretary may make grants to, or enter into 
     contracts with, eligible entities--
       (1) to plan, develop, or implement secondary school health 
     sciences curricula, including curricula in biology, 
     chemistry, physiology, mathematics, nutrition, and other 
     courses deemed appropriate by the Secretary to prepare 
     students for associate's or bachelor's degree programs in 
     health professions or bachelor's degree programs in health 
     professions-related majors; and
       (2) to increase the interest of secondary school students 
     in applying to, and enrolling in, accredited associate's or 
     bachelor's degree programs in health professions or 
     bachelor's degree programs in health professions-related 
     majors, including through--
       (A) work-study programs;
       (B) programs to increase awareness of careers in health 
     professions; and
       (C) other activities to increase such interest.
       (c) Eligibility.--To be eligible for a grant or contract 
     under subsection (b), an entity shall--
       (1) be a local educational agency; and
       (2) provide assurances that activities under the grant or 
     contract will be carried out in partnership with an 
     accredited health professions school or program, public or 
     private nonprofit hospital, or public or private nonprofit 
     entity.
       (d) Preference.--In awarding grants and contracts under 
     subsection (b), the Secretary shall give preference to 
     entities that have a demonstrated record of at least one of 
     the following:
       (1) Graduating a high or significantly improved percentage 
     of students who have exhibited mastery in secondary school 
     State science standards.
       (2) Graduating students from disadvantaged backgrounds, 
     including racial and ethnic minorities who are 
     underrepresented in--
       (A) associate's or bachelor's degree programs in health 
     professions or bachelor's degree programs in health 
     professions-related majors; or
       (B) health professions.
       (e) Report.--The Secretary shall submit to the Congress an 
     annual report on the program carried out under this section.
       (f) Definitions.--In this section:
       (1) The term ``health profession'' means the profession of 
     any member of the health workforce, as defined in section 
     764(i) of the Public Health Service Act, as added by section 
     2261.
       (2) The term ``local educational agency'' has the meaning 
     given to the term in section 9101 of the Elementary and 
     Secondary Education Act of 1965 (20 U.S.C. 7801).
       (3) The term ``secondary school''--
       (A) means a secondary school, as defined in section 9101 of 
     the Elementary and Secondary Education Act of 1965 (20 U.S.C. 
     7801); and
       (B) includes any such school that is a middle school.
       (4) The term ``Secretary'' means the Secretary of Health 
     and Human Services except as otherwise specified.
       (g) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

     SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

       (a) Purpose.--The purpose of this subtitle is to establish 
     and provide assistance to community-based collaborative care 
     networks--
       (1) to develop or strengthen coordination of services to 
     allow all individuals, including the uninsured and low-
     income, to receive efficient and higher quality care and to 
     gain entry into and receive services from a comprehensive 
     system of care;
       (2) to develop efficient and sustainable infrastructure for 
     a health care delivery system characterized by effective 
     collaboration, information sharing, and clinical and 
     financial coordination among providers of care in the 
     community;
       (3) to develop or strengthen activities related to 
     providing coordinated care for individuals with chronic 
     conditions; and
       (4) to reduce the use of emergency departments, inpatient 
     and other expensive resources of hospitals and other 
     providers.
       (b) Creation of the Community-Based Collaborative Care 
     Network Program.--Part D of title III (42 U.S.C. 254b et 
     seq.), as amended, is further amended by inserting after 
     subpart XII the following new subpart:

   ``Subpart XIII--Community-Based Collaborative Care Network Program

     ``SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE NETWORK 
                   PROGRAM.

       ``(a) In General.--The Secretary may award grants to 
     eligible entities for the purpose of establishing model 
     projects to accomplish the following goals:
       ``(1) To reduce unnecessary use of items and services 
     furnished in emergency departments of hospitals (especially 
     to ensure that individuals without health insurance coverage 
     or with inadequate health insurance coverage do not use the 
     services of such department instead of the services of a 
     primary care provider) through methods such as--
       ``(A) screening individuals who seek emergency department 
     services for possible eligibility under relevant governmental 
     health programs or for subsidies under such programs; and
       ``(B) providing such individuals referrals for followup 
     care and chronic condition care.
       ``(2) To manage chronic conditions to reduce their 
     severity, negative health outcomes, and expense.
       ``(3) To encourage health care providers to coordinate 
     their efforts so that the most vulnerable patient populations 
     seek and obtain primary care.
       ``(4) To provide more comprehensive and coordinated care to 
     vulnerable low-income individuals and individuals without 
     health insurance coverage or with inadequate coverage.
       ``(5) To provide mechanisms for improving both quality and 
     efficiency of care for low-income individuals and families, 
     with an emphasis on those most likely to remain uninsured 
     despite the existence of government programs to make health 
     insurance more affordable.
       ``(6) To increase preventive services, including screening 
     and counseling, to those who would otherwise not receive such 
     screening, in order to improve health status and reduce long-
     term complications and costs.
       ``(7) To ensure the availability of community-wide safety 
     net services, including emergency and trauma care.
       ``(b) Eligibility and Grantee Selection.--
       ``(1) Application.--A community-based collaborative care 
     network described in subsection (d) shall submit to the 
     Secretary an application in such form and manner and 
     containing such information as specified by the Secretary. 
     Such information shall at least--
       ``(A) identify the health care providers participating in 
     the community-based collaborative care network proposed by 
     the applicant and, if a provider designated in paragraph 
     (d)(1)(B) is not included, the reason such provider is not so 
     included;
       ``(B) include a description of how the providers plan to 
     collaborate to provide comprehensive and integrated care for 
     low-income individuals, including uninsured and underinsured 
     individuals;
       ``(C) include a description of the organizational and joint 
     governance structure of the community-based collaborative 
     care network in a manner so that it is clear how decisions 
     will be made, and how the decisionmaking process of the 
     network will include appropriate representation of the 
     participating entities;
       ``(D) define the geographic areas and populations that the 
     network intends to serve;
       ``(E) define the scope of services that the network intends 
     to provide and identify any reasons why such services would 
     not include a suggested core service identified by the 
     Secretary under paragraph (3);
       ``(F) demonstrate the network's ability to meet the 
     requirements of this section; and
       ``(G) provide assurances that grant funds received shall be 
     used to support the entire community-based collaborative care 
     network.
       ``(2) Selection of grantees.--

[[Page 27371]]

       ``(A) In general.--The Secretary shall select community-
     based collaborative care networks to receive grants from 
     applications submitted under paragraph (1) on the basis of 
     quality of the proposal involved, geographic diversity 
     (including different States and regions served and urban and 
     rural diversity), and the number of low-income and uninsured 
     individuals that the proposal intends to serve.
       ``(B) Priority.--The Secretary shall give priority to 
     proposals from community-based collaborative care networks 
     that--
       ``(i) include the capability to provide the broadest range 
     of services to low-income individuals; and
       ``(ii) include providers that currently serve a high volume 
     of low-income individuals.
       ``(C) Renewal.--In subsequent years, based on the 
     performance of grantees, the Secretary may provide renewal 
     grants to prior year grant recipients.
       ``(3) Suggested core services.--For purposes of paragraph 
     (1)(E), the Secretary shall develop a list of suggested core 
     patient and core network services to be provided by a 
     community-based collaborative care network. The Secretary may 
     select a community-based collaborative care network under 
     paragraph (2), the application of which does not include all 
     such services, if such application provides a reasonable 
     explanation why such services are not proposed to be 
     included, and the Secretary determines that the application 
     is otherwise high quality.
       ``(4) Termination authority.--The Secretary may terminate 
     selection of a community-based collaborative care network 
     under this section for good cause. Such good cause shall 
     include a determination that the network--
       ``(A) has failed to provide a comprehensive range of 
     coordinated and integrated health care services as required 
     under subsection (d)(2);
       ``(B) has failed to meet reasonable quality standards;
       ``(C) has misappropriated funds provided under this 
     section; or
       ``(D) has failed to make progress toward accomplishing 
     goals set out in subsection (a).
       ``(c) Use of Funds.--
       ``(1) Use by grantees.--Grant funds are provided to 
     community-based collaborative care networks to carry out the 
     following activities:
       ``(A) Assist low-income individuals without adequate health 
     care coverage to--
       ``(i) access and appropriately use health services;
       ``(ii) enroll in applicable public or private health 
     insurance programs;
       ``(iii) obtain referrals to and see a primary care provider 
     in case such an individual does not have a primary care 
     provider; and
       ``(iv) obtain appropriate care for chronic conditions.
       ``(B) Improve heath care by providing case management, 
     application assistance, and appropriate referrals such as 
     through methods to--
       ``(i) create and meaningfully use a health information 
     technology network to track patients across collaborative 
     providers;
       ``(ii) perform health outreach, such as by using 
     neighborhood health workers who may inform individuals about 
     the availability of safety net and primary care providers 
     available through the community-based collaborative care 
     network;
       ``(iii) provide for followup outreach to remind patients of 
     appointments or follow-up care instructions;
       ``(iv) provide transportation to individuals to and from 
     the site of care;
       ``(v) expand the capacity to provide care at any provider 
     participating in the community-based collaborative care 
     network, including telehealth, hiring new clinical or 
     administrative staff, providing access to services after-
     hours, on weekends, or otherwise providing an urgent care 
     alternative to an emergency department; and
       ``(vi) provide a primary care provider or medical home for 
     each network patient.
       ``(C) Provide direct patient care services as described in 
     their application and approved by the Secretary.
       ``(2) Grant funds to hrsa grantees.--The Secretary may 
     limit the percent of grant funding that may be spent on 
     direct care services provided by grantees of programs 
     administered by the Health Resources and Services 
     Administration (in this section referred to as `HRSA') or 
     impose other requirements on HRSA grantees participating in a 
     community-based collaborative care network as may be 
     necessary for consistency with the requirements of such 
     programs.
       ``(3) Reservation of funds for national program purposes.--
     The Secretary may use not more than 7 percent of funds 
     appropriated to carry out this section for providing 
     technical assistance to grantees, obtaining assistance of 
     experts and consultants, holding meetings, developing of 
     tools, disseminating of information, and evaluation.
       ``(d) Community-Based Collaborative Care Networks.--
       ``(1) In general.--
       ``(A) Description.--A community-based collaborative care 
     network described in this subsection is a consortium of 
     health care providers with a joint governance structure that 
     provides a comprehensive range of coordinated and integrated 
     health care services for low-income patient populations or 
     medically underserved communities (whether or not such 
     individuals receive benefits under title XVIII, XIX, or XXI 
     of the Social Security Act, private or other health insurance 
     or are uninsured or underinsured) and that complies with any 
     applicable minimum eligibility requirements that the 
     Secretary may determine appropriate.
       ``(B) Required inclusion.--Each such network shall include 
     the following providers that serve the community (unless such 
     provider does not exist within the community, declines or 
     refuses to participate, or places unreasonable conditions on 
     their participation)--
       ``(i) A safety net hospital that provides services to a 
     high volume of low-income patients, as demonstrated by 
     meeting the criteria in section 1923(b)(1) of the Social 
     Security Act, or other similar criteria determined by the 
     Secretary; and
       ``(ii) All Federally qualified health centers (as defined 
     in section 1861(aa) of the Social Security Act (42 U.S.C. 
     1395x(aa))) located in the geographic area served by the 
     Coordinated Care Network;
       ``(C) Additional inclusions.--Each such network may include 
     any of the following additional providers:
       ``(i) A hospital, including a critical access hospital (as 
     defined in section 1820(c)(2) of the Social Security Act (42 
     U.S.C. 1395i-4(c)(2))).
       ``(ii) A county or municipal department of health.
       ``(iii) A rural health clinic or a rural health network (as 
     defined in sections 1861(aa) and 1820(d) of the Social 
     Security Act, respectively (42 U.S.C. 1395x(aa), 1395i-
     4(d))).
       ``(iv) A community clinic, including a mental health 
     clinic, substance abuse clinic, or a reproductive health 
     clinic.
       ``(v) A health center controlled network as defined by 
     section 330(e)(1)(C) of the Public Health Service Act
       ``(vi) A private practice physician or group practice.
       ``(vii) A nurse or physician assistant or group practice.
       ``(viii) An adult day care center.
       ``(ix) A home health provider.
       ``(x) Any other type of provider specified by the 
     Secretary, which has a desire to serve low-income and 
     uninsured patients.
       ``(D) Construction.--
       ``(i) Nothing in this section shall prohibit a single 
     entity from qualifying as community-based collaborative care 
     network so long as such single entity meets the criteria of a 
     community-based collaborative care network. If the network 
     does not include the providers referenced in clauses (i) and 
     (ii) of subparagraph (B) of this paragraph, the application 
     must explain the reason pursuant to subsection (b)(1)(A).
       ``(ii) Participation in a community-based collaborative 
     care network shall not affect Federally qualified health 
     centers' obligation to comply with the governance 
     requirements under section 330 of the Public Health Service 
     Act (42 U.S.C. 254b).
       ``(iii) Federally qualified health centers participating in 
     a community-based collaborative care network may not be 
     required to provide services beyond their Federal Health 
     Center scope of project approved by HRSA.
       ``(iv) Nothing in this section shall be construed to expand 
     medical malpractice liability protection under the Federal 
     Tort Claims Act for Section 330-funded Federally qualified 
     health centers.
       ``(2) Comprehensive range of coordinated and integrated 
     health care services.--The Secretary shall define criteria 
     for evaluating whether the services offered by a community-
     based collaborative care network qualify as a comprehensive 
     range of coordinated and integrated health care services. 
     Such criteria may vary based on the needs of the geographic 
     areas and populations to be served by the network and may 
     include the following:
       ``(A) Requiring community-based collaborative care networks 
     to include at least the suggested core services identified 
     under subsection (b)(3), or whichever subset of the suggested 
     core services is applicable to a particular network.
       ``(B) Requiring such networks to assign each patient of the 
     network to a primary care provider responsible for managing 
     that patient's care.
       ``(C) Requiring the services provided by a community-based 
     collaborative care network to include support services 
     appropriate to meet the health needs of low-income 
     populations in the network's community, which may include 
     chronic care management, nutritional counseling, 
     transportation, language services, enrollment counselors, 
     social services and other services as proposed by the 
     network.
       ``(D) Providing that the services provided by a community-
     based collaborative care network may also include long-term 
     care services and other services not specified in this 
     subsection.
       ``(E) Providing for the approval by the Secretary of a 
     scope of community-based collaborative care network services 
     for each

[[Page 27372]]

     network that addresses an appropriate minimum scope of work 
     consistent with the setting of the network and the health 
     professionals available in the community the network serves.
       ``(3) Clarification.--Participation in a community-based 
     collaborative care network shall not disqualify a health care 
     provider from reimbursement under title XVIII, XIX, or XXI of 
     the Social Security Act with respect to services otherwise 
     reimbursable under such title. Nothing in this section shall 
     prevent a community-based collaborative care network that is 
     otherwise eligible to contract with Medicare, a private 
     health insurer, or any other appropriate entity to provide 
     care under Medicare, under health insurance coverage offered 
     by the insurer, or otherwise.
       ``(e) Evaluations.--
       ``(1) Grantee reports.--Beginning in the third year 
     following an initial grant, each community-based 
     collaborative care network shall submit to the Secretary, 
     with respect to each year the grantee has received a grant, 
     an evaluation on the activities carried out by the community-
     based collaborative care network under the community-based 
     collaborative care network program and shall include--
       ``(A) the number of people served;
       ``(B) the most common health problems treated;
       ``(C) any reductions in emergency department use;
       ``(D) any improvements in access to primary care;
       ``(E) an accounting of how amounts received were used, 
     including identification of amounts used for patient care 
     services as may be required for HRSA grantees; and
       ``(F) to the extent requested by the Secretary, any quality 
     measures or any other measures specified by the Secretary.
       ``(2) Program reports.--The Secretary shall submit to 
     Congress an annual evaluation (beginning not later than 6 
     months after the first reports under paragraph (1) are 
     submitted) on the extent to which emergency department use 
     was reduced as a result of the activities carried out by the 
     community-based collaborative care network under the program. 
     Each such evaluation shall also include information on--
       ``(A) the prevalence of certain chronic conditions in 
     various populations, including a comparison of such 
     prevalence in the general population versus in the population 
     of individuals with inadequate health insurance coverage;
       ``(B) demographic characteristics of the population of 
     uninsured and underinsured individuals served by the 
     community-based collaborative care network involved; and
       ``(C) the conditions of such individuals for whom services 
     were requested at such emergency departments of participating 
     hospitals.
       ``(3) Audit authority.--The Secretary may conduct periodic 
     audits and request periodic spending reports of community-
     based collaborative care networks under the community-based 
     collaborative care network program.
       ``(f) Clarification.--Nothing in this section requires a 
     provider to report individually identifiable information of 
     an individual to government agencies, unless the individual 
     consents, consistent with HIPAA privacy and security law, as 
     defined in section 3009(a)(2).
       ``(g) Authorization of Appropriations.--There are 
     authorized to be appropriated to carry out this section such 
     sums as may be necessary for each of fiscal years 2011 
     through 2015.''.

     SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION 
                   PROGRAM.

       Part Q of title III (42 U.S.C. 280h et seq.) is amended by 
     inserting after section 399W the following:

     ``SEC. 399W-1. COMMUNITY-BASED OVERWEIGHT AND OBESITY 
                   PREVENTION PROGRAM.

       ``(a) Program.--The Secretary shall establish a community-
     based overweight and obesity prevention program consisting of 
     awarding grants and contracts under subsection (b).
       ``(b) Grants.--The Secretary shall award grants to, or 
     enter into contracts with, eligible entities--
       ``(1) to plan evidence-based programs for the prevention of 
     overweight and obesity among children and their families 
     through improved nutrition and increased physical activity; 
     or
       ``(2) to implement such programs.
       ``(c) Eligibility.--To be eligible for a grant or contract 
     under subsection (b), an entity shall be a community 
     partnership that demonstrates community support and 
     includes--
       ``(1) a broad cross section of stakeholders, such as--
       ``(A) hospitals, health care systems, community health 
     centers, or other health care providers;
       ``(B) universities, local educational agencies, or 
     childcare providers;
       ``(C) State, local, and tribal health departments;
       ``(D) State, local, and tribal park and recreation 
     departments;
       ``(E) employers; and
       ``(F) health insurance companies;
       ``(2) residents of the community; and
       ``(3) representatives of public and private entities that 
     have a history of working within and serving the community.
       ``(d) Period of Awards.--
       ``(1) In general.--The period of a grant or contract under 
     this section shall be 5 years, subject to renewal under 
     paragraph (2).
       ``(2) Renewal.--At the end of each fiscal year, the 
     Secretary may renew a grant or contract award under this 
     section only if the grant or contract recipient demonstrates 
     to the Secretary's satisfaction that the recipient has made 
     appropriate, measurable progress in preventing overweight and 
     obesity.
       ``(e) Requirements.--
       ``(1) In general.--The Secretary may award a grant or 
     contract under this section to an entity only if the entity 
     demonstrates to the Secretary's satisfaction that--
       ``(A) not later than 90 days after receiving the grant or 
     contract, the entity will establish a steering committee to 
     provide input on the assessment of, and recommendations on 
     improvements to, the entity's program funded through the 
     grant or contract; and
       ``(B) the entity has conducted or will conduct an 
     assessment of the overweight and obesity problem in its 
     community, including the extent of the problem and factors 
     contributing to the problem.
       ``(2) Matching requirement.--The Secretary may award a 
     grant or contract to an eligible entity under this section 
     only if the entity agrees to provide, from non-Federal 
     sources, an amount equal to $1 (in cash or in kind) for each 
     $9 provided through the grant or contract to carry out the 
     activities supported by the grant or contract.
       ``(3) Payor of last resort.--The Secretary may award a 
     grant or contract under this section to an entity only if the 
     entity demonstrates to the satisfaction of the Secretary that 
     funds received through the grant or contract will not be 
     expended for any activity to the extent that payment has been 
     made, or can reasonably be expected to be made--
       ``(A) under any insurance policy;
       ``(B) under any Federal or State health benefits program 
     (including titles XIX and XXI of the Social Security Act); or
       ``(C) by an entity which provides health services on a 
     prepaid basis.
       ``(4) Maintenance of effort.--The Secretary may award a 
     grant or contract under this section to an entity only if the 
     entity demonstrates to the satisfaction of the Secretary 
     that--
       ``(A) funds received through the grant or contract will be 
     expended only to supplement, and not supplant, non-Federal 
     and Federal funds otherwise available to the entity for the 
     activities to be funded through the grant or contract; and
       ``(B) with respect to such activities, the entity will 
     maintain expenditures of non-Federal amounts for such 
     activities at a level not less than the lesser of such 
     expenditures maintained by the entity for the fiscal year 
     preceding the fiscal year for which the entity receives the 
     grant or contract.
       ``(f) Preferences.--In awarding grants and contracts under 
     this section, the Secretary shall give preference to eligible 
     entities that--
       ``(1) will serve communities with high levels of overweight 
     and obesity and related chronic diseases; or
       ``(2) will plan or implement activities for the prevention 
     of overweight and obesity in school or workplace settings.
       ``(g) Report.--The Secretary shall submit to the Congress 
     an annual report on the program of grants and contracts 
     awarded under this section.
       ``(h) Definitions.--In this section:
       ``(1) The term `evidence-based' means that methodologically 
     sound research has demonstrated a beneficial health effect in 
     the judgment of the Secretary and includes the Ways to 
     Enhance Children's Activity and Nutrition (We Can) program 
     and curriculum of the National Institutes of Health.
       ``(2) The term `local educational agency' has the meaning 
     given to the term in section 9101 of the Elementary and 
     Secondary Education Act of 1965.
       ``(i) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated $10,000,000 
     for fiscal year 2011 and such sums as may be necessary for 
     each of fiscal years 2012 through 2015.''.

     SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS.

       (a) Demonstration Grants.--
       (1) In general.--The Secretary of Education, in 
     consultation with the Secretary of Health and Human Services 
     and the Director of the Centers for Disease Control and 
     Prevention, may make demonstration grants to eligible local 
     educational agencies for the purpose of reducing the student-
     to-school nurse ratio in public elementary and secondary 
     schools.
       (2) Special consideration.--In awarding grants under this 
     section, the Secretary of Education shall give special 
     consideration to applications submitted by high-need local 
     educational agencies that demonstrate the greatest need for 
     new or additional nursing services among children in the 
     public elementary and secondary schools served by the agency, 
     in part by providing information on current ratios of 
     students to school nurses.
       (3) Matching funds.--The Secretary of Education may require 
     recipients of grants

[[Page 27373]]

     under this subsection to provide matching funds from non-
     Federal sources, and shall permit the recipients to match 
     funds in whole or in part with in-kind contributions.
       (b) Report.--Not later than 24 months after the date on 
     which assistance is first made available to local educational 
     agencies under this section, the Secretary of Education shall 
     submit to the Congress a report on the results of the 
     demonstration grant program carried out under this section, 
     including an evaluation of the effectiveness of the program 
     in improving the student-to-school nurse ratios described in 
     subsection (a) and an evaluation of the impact of any 
     resulting enhanced health of students on learning.
       (c) Definitions.--For purposes of this section:
       (1) The terms ``elementary school'', ``local educational 
     agency'', and ``secondary school'' have the meanings given to 
     those terms in section 9101 of the Elementary and Secondary 
     Education Act of 1965 (20 U.S.C. 7801).
       (2) The term ``eligible local educational agency'' means a 
     local educational agency in which the student-to-school nurse 
     ratio in the public elementary and secondary schools served 
     by the agency is 750 or more students to every school nurse.
       (3) The term ``high-need local educational agency'' means a 
     local educational agency--
       (A) that serves not fewer than 10,000 children from 
     families with incomes below the poverty line; or
       (B) for which not less than 20 percent of the children 
     served by the agency are from families with incomes below the 
     poverty line.
       (4) The term ``nurse'' means a licensed nurse, as defined 
     under State law.
       (d) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

     SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS.

       (a) In General.--The Secretary shall establish a nationwide 
     demonstration project consisting of--
       (1) awarding grants to, and entering into contracts with, 
     medical-legal partnerships to assist patients and their 
     families to navigate health-related programs and activities; 
     and
       (2) evaluating the effectiveness of such partnerships.
       (b) Use of Funds.--Amounts received as a grant or contract 
     under this section shall be used to assist patients and their 
     families to navigate health care-related programs and 
     activities and thereby achieve one or more of the following 
     goals:
       (1) Enhancing access to health care services.
       (2) Improving health outcomes for low-income individuals.
       (3) Reducing health disparities.
       (4) Enhancing wellness and prevention of chronic 
     conditions.
       (c) Prohibition.--No funds under this section may be used--
       (1) for any medical malpractice or other civil action or 
     proceeding; or
       (2) to assist individuals who are not lawfully present in 
     the United States.
       (d) Report.--Not later than 5 years after the date of the 
     enactment of this Act, the Secretary shall submit a report to 
     the Congress on the results of the demonstration project 
     under this section. Such report shall include the following:
       (1) A description of the extent to which medical-legal 
     partnerships funded through this section achieved the goals 
     described in subsection (b).
       (2) Recommendations on the possibility of extending or 
     expanding the demonstration project.
       (e) Definitions.--In this section:
       (1) The term ``health disparities'' has the meaning given 
     to the term in section 3171 of the Public Health Service Act, 
     as added by section 2301.
       (2) The term ``medical-legal partnership'' means an 
     entity--
       (A) that is a collaboration between--
       (i) a community health center, public hospital, children's 
     hospital, or other provider of health care services to a 
     significant number of low-income beneficiaries; and
       (ii) one or more attorneys; and
       (B) whose primary mission is to assist patients and their 
     families navigate health care-related programs and 
     activities.
       (3) The term ``Secretary'' means the Secretary of Health 
     and Human Services.
       (f) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

     SEC. 2538. SCREENING, BRIEF INTERVENTION, REFERRAL, AND 
                   TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE 
                   DISORDERS.

       Part D of title V (42 U.S.C. 290dd et seq.) is amended by 
     adding at the end the following:

     ``SEC. 544. SCREENING, BRIEF INTERVENTION, REFERRAL, AND 
                   TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE 
                   DISORDERS.

       ``(a) Program.--The Secretary, acting through the 
     Administrator, shall establish a program (consisting of 
     awarding grants, contracts, and cooperative agreements under 
     subsection (b)) on mental health and substance abuse 
     screening, brief intervention, referral, and recovery 
     services for individuals in primary health care settings.
       ``(b) Use of Funds.--The Secretary may award grants to, or 
     enter into contracts or cooperative agreements with, 
     entities--
       ``(1) to provide mental health and substance abuse 
     screening, brief interventions, referral, and recovery 
     services;
       ``(2) to coordinate these services with primary health care 
     services in the same program and setting;
       ``(3) to develop a network of facilities to which patients 
     may be referred if needed;
       ``(4) to purchase needed screening and other tools that 
     are--
       ``(A) necessary for providing these services; and
       ``(B) supported by evidence-based research; and
       ``(5) to maintain communication with appropriate State 
     mental health and substance abuse agencies.
       ``(c) Eligibility.--To be eligible for a grant, contract, 
     or cooperative agreement under this section, an entity shall 
     be a public or private nonprofit entity that--
       ``(1) provides primary health services;
       ``(2) seeks to integrate mental health and substance abuse 
     services into its service system;
       ``(3) has developed a working relationship with providers 
     of mental health and substance abuse services;
       ``(4) demonstrates a need for the inclusion of mental 
     health and substance abuse services in its service system; 
     and
       ``(5) agrees--
       ``(A) to prepare and submit to the Secretary at the end of 
     the grant, contract, or cooperative agreement period an 
     evaluation of all activities funded through the grant, 
     contract, or cooperative agreement; and
       ``(B) to use such performance measures as may be stipulated 
     by the Secretary for purposes of such evaluation.
       ``(d) Preference.--In awarding grants, contracts, and 
     cooperative agreements under this section, the Secretary 
     shall give preference to entities that--
       ``(1) provide services in rural or frontier areas of the 
     Nation;
       ``(2) provide services to special needs populations, 
     including American Indian or Alaska Native populations; or
       ``(3) provide services in school-based health clinics or on 
     university and college campuses.
       ``(e) Duration.--The period of a grant, contract, or 
     cooperative agreement under this section may not exceed 5 
     years.
       ``(f) Report.--Not later than 4 years after the first 
     appropriation of funds to carry out this section, the 
     Secretary shall submit a report to the Congress on the 
     program under this section--
       ``(1) including an evaluation of the benefits of 
     integrating mental health and substance abuse care within 
     primary health care; and
       ``(2) focusing on the performance measures stipulated by 
     the Secretary under subsection (c)(5).
       ``(g) Authorization of Appropriations.--
       ``(1) In general.--To carry out this section, there are 
     authorized to be appropriated $30,000,000 for fiscal year 
     2011 and such sums as may be necessary for each of fiscal 
     years 2012 through 2015.
       ``(2) Program management.--Of the funds appropriated to 
     carry out this section for a fiscal year, the Secretary may 
     use not more than 5 percent to manage the program under this 
     section.''.

     SEC. 2539. GRANTS TO ASSIST IN DEVELOPING MEDICAL SCHOOLS IN 
                   FEDERALLY-DESIGNATED HEALTH PROFESSIONAL 
                   SHORTAGE AREAS.

       (a) Grants Authorized.--The Secretary of Health and Human 
     Services may make grants to nonprofit organizations or 
     institutions of higher education for the purpose of assisting 
     the organization or institution involved to develop a medical 
     school if--
       (1) the medical school will be located in an area that is 
     designated (under section 332 of the Public Health Service 
     Act (42 U.S.C. 254(e)) as a health professional shortage 
     area;
       (2) the organization or institution provides assurances 
     satisfactory to the Secretary of substantial private or 
     public funding from non-Federal sources for the development 
     of the medical school; and
       (3) the organization or institution provides assurances 
     satisfactory to the Secretary that accreditation will be 
     achieved for the medical school.
       (b) Use of Grant Funds.--Grants awarded under this section 
     may be used for the acquisition and building of the medical 
     school campus in a health professional shortage area and the 
     purchase of equipment, curriculum and faculty development, 
     and general operations related to the development and 
     establishment of the medical school.
       (c) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there is authorized to be 
     appropriated $100,000,000 for each of fiscal years 2011 
     through 2015.
       Page 1523, strike lines 5 through 17 and insert the 
     following:
       ``(i) In general.--A violation of subparagraph (A) shall be 
     subject to enforcement by the Federal Trade Commission in the 
     same manner, by the same means, and with the same 
     jurisdiction as would an unfair and deceptive act or practice 
     in or affecting interstate commerce or an unfair method of 
     competition in or affecting interstate commerce

[[Page 27374]]

     prohibited under section 5 of the Federal Trade Commission 
     Act, as though all applicable terms and provisions of the 
     Federal Trade Commission Act were incorporated into and made 
     a part of this subsection.

                PART 3--EMERGENCY CARE-RELATED PROGRAMS

     SEC. 2551. TRAUMA CARE CENTERS.

       (a) Grants for Trauma Care Centers.--Section 1241 (42 
     U.S.C. 300d-41) is amended to read as follows:

     ``SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS.

       ``(a) In General.--The Secretary shall establish a trauma 
     center program consisting of awarding grants under section 
     (b).
       ``(b) Grants.--The Secretary shall award grants as follows:
       ``(1) Existing centers.--Grants to public, private 
     nonprofit, Indian Health Service, Indian tribal, and urban 
     Indian trauma centers--
       ``(A) to further the core missions of such centers; or
       ``(B) to provide emergency relief to ensure the continued 
     and future availability of trauma services by trauma 
     centers--
       ``(i) at risk of closing or operating in an area where a 
     closing has occurred within their primary service area; or
       ``(ii) in need of financial assistance following a natural 
     disaster or other catastrophic event, such as a terrorist 
     attack.
       ``(2) New centers.--Grants to local governments and public 
     or private nonprofit entities to establish new trauma centers 
     in urban areas with a substantial degree of trauma resulting 
     from violent crimes.
       ``(c) Minimum Qualifications of Trauma Centers.--
       ``(1) Participation in trauma care system operating under 
     certain professional guidelines.--
       ``(A) Limitation.--Subject to subparagraph (B), the 
     Secretary may not award a grant to an existing trauma center 
     under this section unless the center is a participant in a 
     trauma care system that substantially complies with section 
     1213.
       ``(B) Exemption.--Subparagraph (A) shall not apply to 
     trauma centers that are located in States with no existing 
     trauma care system.
       ``(2) Designation.--The Secretary may not award a grant 
     under this section to an existing trauma center unless the 
     center is--
       ``(A) verified as a trauma center by the American College 
     of Surgeons; or
       ``(B) designated as a trauma center by the applicable State 
     health or emergency medical services authority.''.
       (b) Considerations in Making Grants.--Section 1242 (42 
     U.S.C. 300d-42) is amended to read as follows:

     ``SEC. 1242. CONSIDERATIONS IN MAKING GRANTS.

       ``(a) Core Mission Awards.--
       ``(1) In general.--In awarding grants under section 
     1241(b)(1)(A), the Secretary shall--
       ``(A) reserve a minimum of 25 percent of the amount 
     allocated for such grants for level III and level IV trauma 
     centers in rural or underserved areas;
       ``(B) reserve a minimum of 25 percent of the amount 
     allocated for such grants for level I and level II trauma 
     centers in urban areas; and
       ``(C) give preference to any application made by a trauma 
     center--
       ``(i) in a geographic area where growth in demand for 
     trauma services exceeds capacity;
       ``(ii) that demonstrates the financial support of the State 
     or political subdivision involved;
       ``(iii) that has at least 1 graduate medical education 
     fellowship in trauma or trauma-related specialties, including 
     neurological surgery, surgical critical care, vascular 
     surgery, and spinal cord injury, for which demand is 
     exceeding supply; or
       ``(iv) that demonstrates a substantial commitment to 
     serving vulnerable populations.
       ``(2) Financial support.--For purposes of paragraph 
     (1)(C)(ii), financial support may be demonstrated by State or 
     political subdivision funding for the trauma center's capital 
     or operating expenses (including through State trauma 
     regional advisory coordination activities, Medicaid funding 
     designated for trauma services, or other governmental 
     funding). State funding derived from Federal support shall 
     not constitute State or local financial support for purposes 
     of preferential treatment under this subsection.
       ``(3) Use of funds.--The recipient of a grant under section 
     1241(b)(1)(A) shall carry out, consistent with furthering the 
     core missions of the center, one or more of the following 
     activities:
       ``(A) Providing 24-hour-a-day, 7-day-a-week trauma care 
     availability.
       ``(B) Reducing overcrowding related to throughput of trauma 
     patients.
       ``(C) Enhancing trauma surge capacity.
       ``(D) Ensuring physician and essential personnel 
     availability.
       ``(E) Trauma education and outreach.
       ``(F) Coordination with local and regional trauma care 
     systems.
       ``(G) Such other activities as the Secretary may deem 
     appropriate.
       ``(b) Emergency Awards; New Centers.--In awarding grants 
     under paragraphs (1)(B) and (2) of section 1241(b), the 
     Secretary shall--
       ``(1) give preference to any application submitted by an 
     applicant that demonstrates the financial support (in 
     accordance with subsection (a)(2)) of the State or political 
     subdivision involved for the activities to be funded through 
     the grant for each fiscal year during which payments are made 
     to the center under the grant; and
       ``(2) give preference to any application submitted for a 
     trauma center that--
       ``(A) is providing or will provide trauma care in a 
     geographic area in which the availability of trauma care has 
     either significantly decreased as a result of a trauma center 
     in the area permanently ceasing participation in a system 
     described in section 1241(c)(1) as of a date occurring during 
     the 2-year period preceding the fiscal year for which the 
     trauma center is applying to receive a grant, or in 
     geographic areas where growth in demand for trauma services 
     exceeds capacity;
       ``(B) will, in providing trauma care during the 1-year 
     period beginning on the date on which the application for the 
     grant is submitted, incur substantial uncompensated care 
     costs in an amount that renders the center unable to continue 
     participation in such system and results in a significant 
     decrease in the availability of trauma care in the geographic 
     area;
       ``(C) operates or will operate in rural areas where trauma 
     care availability will significantly decrease if the center 
     is forced to close or downgrade service and substantial costs 
     are contributing to a likelihood of such closure or 
     downgradation;
       ``(D) is in a geographic location substantially affected by 
     a natural disaster or other catastrophic event such as a 
     terrorist attack; or
       ``(E) will establish a new trauma service in an urban area 
     with a substantial degree of trauma resulting from violent 
     crimes.
       ``(c) Designations of Levels of Trauma Centers in Certain 
     States.--In the case of a State which has not designated 4 
     levels of trauma centers, any reference in this section to--
       ``(1) a level I or level II trauma center is deemed to be a 
     reference to a trauma center within the highest 2 levels of 
     trauma centers designated under State guidelines; and
       ``(2) a level III or IV trauma center is deemed to be a 
     reference to a trauma center not within such highest 2 
     levels.''.
       (c) Certain Agreements.--Section 1243 (42 U.S.C. 300d-43) 
     is amended to read as follows:

     ``SEC. 1243. CERTAIN AGREEMENTS.

       ``(a) Commitment Regarding Continued Participation in 
     Trauma Care System.--The Secretary may not award a grant to 
     an applicant under section 1241(b) unless the applicant 
     agrees that--
       ``(1) the trauma center involved will continue 
     participation, or in the case of a new center will 
     participate, in the system described in section 1241(c)(1), 
     except as provided in section 1241(c)(1)(B), throughout the 
     grant period beginning on the date that the center first 
     receives payments under the grant; and
       ``(2) if the agreement made pursuant to paragraph (1) is 
     violated by the center, the center will be liable to the 
     United States for an amount equal to the sum of--
       ``(A) the amount of assistance provided to the center under 
     section 1241; and
       ``(B) an amount representing interest on the amount 
     specified in subparagraph (A).
       ``(b) Maintenance of Financial Support.--With respect to 
     activities for which funds awarded through a grant under 
     section 1241 are authorized to be expended, the Secretary may 
     not award such a grant unless the applicant agrees that, 
     during the period in which the trauma center involved is 
     receiving payments under the grant, the center will maintain 
     access to trauma services at levels not less than the levels 
     for the prior year, taking into account--
       ``(1) reasonable volume fluctuation that is not caused by 
     intentional trauma boundary reduction;
       ``(2) downgrading of the level of services; and
       ``(3) whether such center diverts its incoming patients 
     away from such center 5 percent or more of the time during 
     which the center is in operation over the course of the year.
       ``(c) Trauma Care Registry.--The Secretary may not award a 
     grant to a trauma center under section 1241(b)(1) unless the 
     center agrees that--
       ``(1) not later than 6 months after the date on which the 
     center submits a grant application to the Secretary, the 
     center will establish and operate a registry of trauma cases 
     in accordance with guidelines developed by the American 
     College of Surgeons; and
       ``(2) in carrying out paragraph (1), the center will 
     maintain information on the number of trauma cases treated by 
     the center and, for each such case, the extent to which the 
     center incurs uncompensated costs in providing trauma 
     care.''.
       (d) General Provisions.--Section 1244 (42 U.S.C. 300d-44) 
     is amended to read as follows:

     ``SEC. 1244. GENERAL PROVISIONS.

       ``(a) Limitation on Duration of Support.--The period during 
     which a trauma center receives payments under a grant under 
     section 1241(b)(1) shall be for 3 fiscal years, except that 
     the Secretary may waive such requirement for the center and 
     authorize the center to receive such payments for 1 
     additional fiscal year.
       ``(b) Eligibility.--The acquisition of, or eligibility for, 
     a grant under section 1241(b)

[[Page 27375]]

     shall not preclude a trauma center's eligibility for another 
     grant described in such section.
       ``(c) Funding Distribution.--Of the total amount 
     appropriated for a fiscal year under section 1245--
       ``(1) 90 percent shall be used for grants under paragraph 
     (1)(A) of section 1241(b); and
       ``(2) 10 percent shall be used for grants under paragraphs 
     (1)(B) and (2) of section 1241(b).
       ``(d) Report.--Beginning 2 years after the date of the 
     enactment of the Affordable Health Care for America Act, and 
     every 2 years thereafter, the Secretary shall biennially--
       ``(1) report to Congress on the status of the grants made 
     pursuant to section 1241;
       ``(2) evaluate and report to Congress on the overall 
     financial stability of trauma centers in the United States;
       ``(3) report on the populations using trauma care centers 
     and include aggregate patient data on income, race, 
     ethnicity, and geography; and
       ``(4) evaluate the effectiveness and efficiency of trauma 
     care center activities using standard public health measures 
     and evaluation methodologies.''.
       (e) Authorization of Appropriations.--Section 1245 (42 
     U.S.C. 300d-45) is amended to read as follows:

     ``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.

       ``(a) In General.--For the purpose of carrying out this 
     part, there are authorized to be appropriated $100,000,000 
     for fiscal year 2011, and such sums as may be necessary for 
     each of fiscal years 2012 through 2015. Such authorization of 
     appropriations is in addition to any other authorization of 
     appropriations or amounts that are available for such 
     purpose.
       ``(b) Reallocation.--The Secretary shall reallocate for 
     grants under section 1241(b)(1)(A) any funds appropriated for 
     grants under paragraph (1)(B) or (2) of section 1241(b), but 
     not obligated due to insufficient applications eligible for 
     funding.''.

     SEC. 2552. EMERGENCY CARE COORDINATION.

       (a) In General.--Subtitle B of title XXVIII (42 U.S.C. 
     300hh-10 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 2816. EMERGENCY CARE COORDINATION.

       ``(a) Emergency Care Coordination Center.--
       ``(1) Establishment.--The Secretary shall establish, within 
     the Office of the Assistant Secretary for Preparedness and 
     Response, an Emergency Care Coordination Center (in this 
     section referred to as the `Center'), to be headed by a 
     director.
       ``(2) Duties.--The Secretary, acting through the Director 
     of the Center, in coordination with the Federal Interagency 
     Committee on Emergency Medical Services, shall--
       ``(A) promote and fund research in emergency medicine and 
     trauma health care;
       ``(B) promote regional partnerships and more effective 
     emergency medical systems in order to enhance appropriate 
     triage, distribution, and care of routine community patients; 
     and
       ``(C) promote local, regional, and State emergency medical 
     systems' preparedness for and response to public health 
     events.
       ``(b) Council of Emergency Care.--
       ``(1) Establishment.--The Secretary, acting through the 
     Director of the Center, shall establish a Council of 
     Emergency Care to provide advice and recommendations to the 
     Director on carrying out this section.
       ``(2) Composition.--The Council shall be comprised of 
     employees of the departments and agencies of the Federal 
     Government who are experts in emergency care and management.
       ``(c) Report.--
       ``(1) Submission.--Not later than 12 months after the date 
     of the enactment of the Affordable Health Care for America 
     Act, the Secretary shall submit to the Congress an annual 
     report on the activities carried out under this section.
       ``(2) Considerations.--In preparing a report under 
     paragraph (1), the Secretary shall consider factors 
     including--
       ``(A) emergency department crowding and boarding; and
       ``(B) delays in care following presentation.
       ``(d) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 
     2015.''.
       (b) Functions, Personnel, Assets, Liabilities, and 
     Administrative Actions.--All functions, personnel, assets, 
     and liabilities of, and administrative actions applicable to, 
     the Emergency Care Coordination Center, as in existence on 
     the day before the date of the enactment of this Act, shall 
     be transferred to the Emergency Care Coordination Center 
     established under section 2816(a) of the Public Health 
     Service Act, as added by subsection (a).

     SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY MEDICAL CARE.

       Part B of title III (42 U.S.C. 243 et seq.) is amended by 
     inserting after section 314 the following:

     ``SEC. 315. REGIONALIZED COMMUNICATION SYSTEMS FOR EMERGENCY 
                   CARE RESPONSE.

       ``(a) In General.--The Secretary, acting through the 
     Assistant Secretary for Preparedness and Response, shall 
     award not fewer than 4 multiyear contracts or competitive 
     grants to eligible entities to support demonstration programs 
     that design, implement, and evaluate innovative models of 
     regionalized, comprehensive, and accountable emergency care 
     systems.
       ``(b) Eligible Entity; Region.--
       ``(1) Eligible entity.--In this section, the term `eligible 
     entity' means a State or a partnership of 1 or more States 
     and 1 or more local governments.
       ``(2) Region.--In this section, the term `region' means an 
     area within a State, an area that lies within multiple 
     States, or a similar area (such as a multicounty area), as 
     determined by the Secretary.
       ``(c) Demonstration Program.--The Secretary shall award a 
     contract or grant under subsection (a) to an eligible entity 
     that proposes a demonstration program to design, implement, 
     and evaluate an emergency medical system that--
       ``(1) coordinates with public safety services, public 
     health services, emergency medical services, medical 
     facilities, and other entities within a region;
       ``(2) coordinates an approach to emergency medical system 
     access throughout the region, including 9-1-1 public safety 
     answering points and emergency medical dispatch;
       ``(3) includes a mechanism, such as a regional medical 
     direction or transport communications system, that operates 
     throughout the region to ensure that the correct patient is 
     taken to the medically appropriate facility (whether an 
     initial facility or a higher level facility) in a timely 
     fashion;
       ``(4) allows for the tracking of prehospital and hospital 
     resources, including inpatient bed capacity, emergency 
     department capacity, on-call specialist coverage, ambulance 
     diversion status, and the coordination of such tracking with 
     regional communications and hospital destination decisions; 
     and
       ``(5) includes a consistent regionwide prehospital, 
     hospital, and interfacility data management system that--
       ``(A) complies with the National EMS Information System, 
     the National Trauma Data Bank, and others;
       ``(B) reports data to appropriate Federal and State 
     databanks and registries; and
       ``(C) contains information sufficient to evaluate key 
     elements of prehospital care, hospital destination decisions, 
     including initial hospital and interfacility decisions, and 
     relevant outcomes of hospital care.
       ``(d) Application.--
       ``(1) In general.--An eligible entity that seeks a contract 
     or grant described in subsection (a) shall submit to the 
     Secretary an application at such time and in such manner as 
     the Secretary may require.
       ``(2) Application information.--Each application shall 
     include--
       ``(A) an assurance from the eligible entity that the 
     proposed system--
       ``(i) has been coordinated with the applicable State office 
     of emergency medical services (or equivalent State office);
       ``(ii) is compatible with the applicable State emergency 
     medical services system;
       ``(iii) includes consistent indirect and direct medical 
     oversight of prehospital, hospital, and interfacility 
     transport throughout the region;
       ``(iv) coordinates prehospital treatment and triage, 
     hospital destination, and interfacility transport throughout 
     the region;
       ``(v) includes a categorization or designation system for 
     special medical facilities throughout the region that is--

       ``(I) consistent with State laws and regulations; and
       ``(II) integrated with the protocols for transport and 
     destination throughout the region; and

       ``(vi) includes a regional medical direction system, a 
     patient tracking system, and a resource allocation system 
     that--

       ``(I) support day-to-day emergency care system operation;
       ``(II) can manage surge capacity during a major event or 
     disaster; and
       ``(III) are integrated with other components of the 
     national and State emergency preparedness system;

       ``(B) an agreement to make available non-Federal 
     contributions in accordance with subsection (e); and
       ``(C) such other information as the Secretary may require.
       ``(e) Matching Funds.--
       ``(1) In general.--With respect to the costs of the 
     activities to be carried out each year with a contract or 
     grant under subsection (a), a condition for the receipt of 
     the contract or grant is that the eligible entity involved 
     agrees to make available (directly or through donations from 
     public or private entities) non-Federal contributions toward 
     such costs in an amount that is not less than 25 percent of 
     such costs.
       ``(2) Determination of amount contributed.--Non-Federal 
     contributions required in paragraph (1) may be in cash or in 
     kind, fairly evaluated, including plant, equipment, or 
     services. Amounts provided by the Federal Government, or 
     services assisted or subsidized to any significant extent by 
     the Federal Government, may not be included in determining 
     the amount of such non-Federal contributions.
       ``(f) Priority.--The Secretary shall give priority for the 
     award of the contracts or

[[Page 27376]]

     grants described in subsection (a) to any eligible entity 
     that serves a medically underserved population (as defined in 
     section 330(b)(3)).
       ``(g) Report.--Not later than 90 days after the completion 
     of a demonstration program under subsection (a), the 
     recipient of such contract or grant described in such 
     subsection shall submit to the Secretary a report containing 
     the results of an evaluation of the program, including an 
     identification of--
       ``(1) the impact of the regional, accountable emergency 
     care system on patient outcomes for various critical care 
     categories, such as trauma, stroke, cardiac emergencies, and 
     pediatric emergencies;
       ``(2) the system characteristics that contribute to the 
     effectiveness and efficiency of the program (or lack 
     thereof);
       ``(3) methods of assuring the long-term financial 
     sustainability of the emergency care system;
       ``(4) the State and local legislation necessary to 
     implement and to maintain the system; and
       ``(5) the barriers to developing regionalized, accountable 
     emergency care systems, as well as the methods to overcome 
     such barriers.
       ``(h) Evaluation.--The Secretary, acting through the 
     Assistant Secretary for Preparedness and Response, shall 
     enter into a contract with an academic institution or other 
     entity to conduct an independent evaluation of the 
     demonstration programs funded under subsection (a), including 
     an evaluation of--
       ``(1) the performance of the eligible entities receiving 
     the funds; and
       ``(2) the impact of the demonstration programs.
       ``(i) Dissemination of Findings.--The Secretary shall, as 
     appropriate, disseminate to the public and to the appropriate 
     committees of the Congress, the information contained in a 
     report made under subsection (h).
       ``(j) Authorization of Appropriations.--
       ``(1) In general.--There is authorized to be appropriated 
     to carry out this section $12,000,000 for each of fiscal 
     years 2011 through 2015.
       ``(2) Reservation.--Of the amount appropriated to carry out 
     this section for a fiscal year, the Secretary shall reserve 3 
     percent of such amount to carry out subsection (h) (relating 
     to an independent evaluation).''.

     SEC. 2554. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL 
                   TRAINING TO BECOME STATE-LICENSED OR CERTIFIED 
                   EMERGENCY MEDICAL TECHNICIANS (EMTS).

       (a) In General.--Part B of title III (42 U.S.C. 243 et 
     seq.), as amended, is amended by inserting after section 315 
     the following:

     ``SEC. 315A. ASSISTING VETERANS WITH MILITARY EMERGENCY 
                   MEDICAL TRAINING TO BECOME STATE-LICENSED OR 
                   CERTIFIED EMERGENCY MEDICAL TECHNICIANS (EMTS).

       ``(a) Program.--The Secretary shall establish a program 
     consisting of awarding grants to States to assist veterans 
     who received and completed military emergency medical 
     training while serving in the Armed Forces of the United 
     States to become, upon their discharge or release from active 
     duty service, State-licensed or certified emergency medical 
     technicians.
       ``(b) Use of Funds.--Amounts received as a grant under this 
     section may be used to assist veterans described in 
     subsection (a) to become State-licensed or certified 
     emergency medical technicians as follows:
       ``(1) Providing training.
       ``(2) Providing reimbursement for costs associated with--
       ``(A) training; or
       ``(B) applying for licensure or certification.
       ``(3) Expediting the licensing or certification process.
       ``(c) Eligibility.--To be eligible for a grant under this 
     section, a State shall demonstrate to the Secretary's 
     satisfaction that the State has a shortage of emergency 
     medical technicians.
       ``(d) Report.--The Secretary shall submit to the Congress 
     an annual report on the program under this section.
       ``(e) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 
     2015.''.
       (b) GAO Study and Report.--The Comptroller General of the 
     United States shall--
       (1) conduct a study on the barriers experienced by veterans 
     who received training as medical personnel while serving in 
     the Armed Forces of the United States and, upon their 
     discharge or release from active duty service, seek to become 
     licensed or certified in a State as civilian health 
     professionals; and
       (2) not later than 2 years after the date of the enactment 
     of this Act, submit to the Congress a report on the results 
     of such study, including recommendations on whether the 
     program established under section 315A of the Public Health 
     Service Act, as added by subsection (a), should be expanded 
     to assist veterans seeking to become licensed or certified in 
     a State as health providers other than emergency medical 
     technicians.

     SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC HEALTH AND 
                   MEDICAL RESPONSE.

       (a) National Health Security Strategy.--Section 2802(b)(3) 
     (42 U.S.C. 300hh-1(b)(3)) is amended--
       (1) in the matter preceding subparagraph (A), by inserting 
     ``dental and'' before ``mental health facilities''; and
       (2) in subparagraph (D), by inserting ``and dental'' after 
     ``medical''.
       (b) All-Hazards Public Health and Medical Response 
     Curricula and Training.--Section 319F(a)(5)(B) (42 U.S.C. 
     247d-6(a)(5)(B)) is amended by striking ``public health or 
     medical'' and inserting ``public health, medical, or 
     dental''.

     SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND SECURITY.

       (a) National Response Framework.--Paragraph (6) of section 
     2 of the Homeland Security Act of 2002 (6 U.S.C. 101) is 
     amended by inserting ``and dental'' after ``emergency 
     medical''.
       (b) National Preparedness System.--Subparagraph (B) of 
     section 653(b)(4) of the Post-Katrina Emergency Management 
     Reform Act of 2006 (6 U.S.C. 753(b)(4)) is amended by 
     striking ``public health and medical'' and inserting ``public 
     health, medical, and dental''.
       (c) Chief Medical Officer.--Paragraph (5) of section 516(c) 
     of the Homeland Security Act of 2002 (6 U.S.C. 321e(c)) is 
     amended by striking ``medical community'' and inserting 
     ``medical and dental communities''.

               PART 4--PAIN CARE AND MANAGEMENT PROGRAMS

     SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN.

       (a) Convening.--Not later than June 30, 2011, the Secretary 
     of Health and Human Services shall seek to enter into an 
     agreement with the Institute of Medicine of the National 
     Academies to convene a Conference on Pain (in this section 
     referred to as ``the Conference'').
       (b) Purposes.--The purposes of the Conference shall be to--
       (1) increase the recognition of pain as a significant 
     public health problem in the United States;
       (2) evaluate the adequacy of assessment, diagnosis, 
     treatment, and management of acute and chronic pain in the 
     general population, and in identified racial, ethnic, gender, 
     age, and other demographic groups that may be 
     disproportionately affected by inadequacies in the 
     assessment, diagnosis, treatment, and management of pain;
       (3) identify barriers to appropriate pain care, including--
       (A) lack of understanding and education among employers, 
     patients, health care providers, regulators, and third-party 
     payors;
       (B) barriers to access to care at the primary, specialty, 
     and tertiary care levels, including barriers--
       (i) specific to those populations that are 
     disproportionately undertreated for pain;
       (ii) related to physician concerns over regulatory and law 
     enforcement policies applicable to some pain therapies; and
       (iii) attributable to benefit, coverage, and payment 
     policies in both the public and private sectors; and
       (C) gaps in basic and clinical research on the symptoms and 
     causes of pain, and potential assessment methods and new 
     treatments to improve pain care; and
       (4) establish an agenda for action in both the public and 
     private sectors that will reduce such barriers and 
     significantly improve the state of pain care research, 
     education, and clinical care in the United States.
       (c) Other Appropriate Entity.--If the Institute of Medicine 
     declines to enter into an agreement under subsection (a), the 
     Secretary of Health and Human Services may enter into such 
     agreement with another appropriate entity.
       (d) Report.--A report summarizing the Conference's findings 
     and recommendations shall be submitted to the Congress not 
     later than June 30, 2012.
       (e) Authorization of Appropriations.--For the purpose of 
     carrying out this section, there is authorized to be 
     appropriated $500,000 for each of fiscal years 2011 and 2012.

     SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF HEALTH.

       Part B of title IV (42 U.S.C. 284 et seq.) is amended by 
     adding at the end the following:

     ``SEC. 409J. PAIN RESEARCH.

       ``(a) Research Initiatives.--
       ``(1) In general.--The Director of NIH is encouraged to 
     continue and expand, through the Pain Consortium, an 
     aggressive program of basic and clinical research on the 
     causes of and potential treatments for pain.
       ``(2) Annual recommendations.--Not less than annually, the 
     Pain Consortium, in consultation with the Division of Program 
     Coordination, Planning, and Strategic Initiatives, shall 
     develop and submit to the Director of NIH recommendations on 
     appropriate pain research initiatives that could be 
     undertaken with funds reserved under section 402A(c)(1) for 
     the Common Fund or otherwise available for such initiatives.
       ``(3) Definition.--In this subsection, the term `Pain 
     Consortium' means the Pain Consortium of the National 
     Institutes of Health or a similar trans-National Institutes 
     of Health coordinating entity designated by the Secretary for 
     purposes of this subsection.
       ``(b) Interagency Pain Research Coordinating Committee.--
       ``(1) Establishment.--The Secretary shall establish not 
     later than 1 year after the date

[[Page 27377]]

     of the enactment of this section and as necessary maintain a 
     committee, to be known as the Interagency Pain Research 
     Coordinating Committee (in this section referred to as the 
     `Committee'), to coordinate all efforts within the Department 
     of Health and Human Services and other Federal agencies that 
     relate to pain research.
       ``(2) Membership.--
       ``(A) In general.--The Committee shall be composed of the 
     following voting members:
       ``(i) Not more than 7 voting Federal representatives as 
     follows:

       ``(I) The Director of the Centers for Disease Control and 
     Prevention.
       ``(II) The Director of the National Institutes of Health 
     and the directors of such national research institutes and 
     national centers as the Secretary determines appropriate.
       ``(III) The heads of such other agencies of the Department 
     of Health and Human Services as the Secretary determines 
     appropriate.
       ``(IV) Representatives of other Federal agencies that 
     conduct or support pain care research and treatment, 
     including the Department of Defense and the Department of 
     Veterans Affairs.

       ``(ii) Twelve additional voting members appointed under 
     subparagraph (B).
       ``(B) Additional members.--The Committee shall include 
     additional voting members appointed by the Secretary as 
     follows:
       ``(i) Six members shall be appointed from among scientists, 
     physicians, and other health professionals, who--

       ``(I) are not officers or employees of the United States;
       ``(II) represent multiple disciplines, including clinical, 
     basic, and public health sciences;
       ``(III) represent different geographical regions of the 
     United States; and
       ``(IV) are from practice settings, academia, manufacturers, 
     or other research settings.

       ``(ii) Six members shall be appointed from members of the 
     general public, who are representatives of leading research, 
     advocacy, and service organizations for individuals with 
     pain-related conditions.
       ``(C) Nonvoting members.--The Committee shall include such 
     nonvoting members as the Secretary determines to be 
     appropriate.
       ``(3) Chairperson.--The voting members of the Committee 
     shall select a chairperson from among such members. The 
     selection of a chairperson shall be subject to the approval 
     of the Director of NIH.
       ``(4) Meetings.--The Committee shall meet at the call of 
     the chairperson of the Committee or upon the request of the 
     Director of NIH, but in no case less often than once each 
     year.
       ``(5) Duties.--The Committee shall--
       ``(A) develop a summary of advances in pain care research 
     supported or conducted by the Federal agencies relevant to 
     the diagnosis, prevention, and treatment of pain and diseases 
     and disorders associated with pain;
       ``(B) identify critical gaps in basic and clinical research 
     on the symptoms and causes of pain;
       ``(C) make recommendations to ensure that the activities of 
     the National Institutes of Health and other Federal agencies, 
     including the Department of Defense and the Department of 
     Veteran Affairs, are free of unnecessary duplication of 
     effort;
       ``(D) make recommendations on how best to disseminate 
     information on pain care; and
       ``(E) make recommendations on how to expand partnerships 
     between public entities, including Federal agencies, and 
     private entities to expand collaborative, crosscutting 
     research.
       ``(6) Review.--The Secretary shall review the necessity of 
     the Committee at least once every 2 years.''.

     SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MANAGEMENT.

       Part B of title II (42 U.S.C. 238 et seq.) is amended by 
     adding at the end the following:

     ``SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARENESS 
                   CAMPAIGN ON PAIN MANAGEMENT.

       ``(a) Establishment.--Not later than 12 months after the 
     date of the enactment of this section, the Secretary shall 
     establish and implement a national pain care education 
     outreach and awareness campaign described in subsection (b).
       ``(b) Requirements.--The Secretary shall design the public 
     awareness campaign under this section to educate consumers, 
     patients, their families, and other caregivers with respect 
     to--
       ``(1) the incidence and importance of pain as a national 
     public health problem;
       ``(2) the adverse physical, psychological, emotional, 
     societal, and financial consequences that can result if pain 
     is not appropriately assessed, diagnosed, treated, or 
     managed;
       ``(3) the availability, benefits, and risks of all pain 
     treatment and management options;
       ``(4) having pain promptly assessed, appropriately 
     diagnosed, treated, and managed, and regularly reassessed 
     with treatment adjusted as needed;
       ``(5) the role of credentialed pain management specialists 
     and subspecialists, and of comprehensive interdisciplinary 
     centers of treatment expertise;
       ``(6) the availability in the public, nonprofit, and 
     private sectors of pain management-related information, 
     services, and resources for consumers, employers, third-party 
     payors, patients, their families, and caregivers, including 
     information on--
       ``(A) appropriate assessment, diagnosis, treatment, and 
     management options for all types of pain and pain-related 
     symptoms; and
       ``(B) conditions for which no treatment options are yet 
     recognized; and
       ``(7) other issues the Secretary deems appropriate.
       ``(c) Consultation.--In designing and implementing the 
     public awareness campaign required by this section, the 
     Secretary shall consult with organizations representing 
     patients in pain and other consumers, employers, physicians 
     including physicians specializing in pain care, other pain 
     management professionals, medical device manufacturers, and 
     pharmaceutical companies.
       ``(d) Coordination.--
       ``(1) Lead official.--The Secretary shall designate one 
     official in the Department of Health and Human Services to 
     oversee the campaign established under this section.
       ``(2) Agency coordination.--The Secretary shall ensure the 
     involvement in the public awareness campaign under this 
     section of the Surgeon General of the Public Health Service, 
     the Director of the Centers for Disease Control and 
     Prevention, and such other representatives of offices and 
     agencies of the Department of Health and Human Services as 
     the Secretary determines appropriate.
       ``(e) Underserved Areas and Populations.--In designing the 
     public awareness campaign under this section, the Secretary 
     shall--
       ``(1) take into account the special needs of geographic 
     areas and racial, ethnic, gender, age, and other demographic 
     groups that are currently underserved; and
       ``(2) provide resources that will reduce disparities in 
     access to appropriate diagnosis, assessment, and treatment.
       ``(f) Grants and Contracts.--The Secretary may make awards 
     of grants, cooperative agreements, and contracts to public 
     agencies and private nonprofit organizations to assist with 
     the development and implementation of the public awareness 
     campaign under this section.
       ``(g) Evaluation and Report.--Not later than the end of 
     fiscal year 2012, the Secretary shall prepare and submit to 
     the Congress a report evaluating the effectiveness of the 
     public awareness campaign under this section in educating the 
     general public with respect to the matters described in 
     subsection (b).
       ``(h) Authorization of Appropriations.--For purposes of 
     carrying out this section, there are authorized to be 
     appropriated $2,000,000 for fiscal year 2011 and $4,000,000 
     for each of fiscal years 2012 and 2015.''.

                Subtitle C--Food and Drug Administration

                           PART 1--IN GENERAL

     SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY.

       (a) Registry.--
       (1) In general.--Section 519 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 360i) is amended--
       (A) by redesignating subsection (g) as subsection (h); and
       (B) by inserting after subsection (f) the following:

                   ``National Medical Device Registry

       ``(g)(1)(A) The Secretary shall establish a national 
     medical device registry (in this subsection referred to as 
     the `registry') to facilitate analysis of postmarket safety 
     and outcomes data on each covered device.
       ``(B) In this subsection, the term `covered device'--
       ``(i) shall include each class III device; and
       ``(ii) may include, as the Secretary determines appropriate 
     and specifies in regulation, a class II device that is life-
     supporting or life-sustaining.
       ``(C) Notwithstanding subparagraph (B)(i), the Secretary 
     may by order exempt a class III device from the provisions of 
     this subsection if the Secretary concludes that inclusion of 
     information on the device in the registry will not provide 
     useful information on safety or effectiveness.
       ``(2) In developing the registry, the Secretary shall, in 
     consultation with the Commissioner of Food and Drugs, the 
     Administrator of the Centers for Medicare & Medicaid 
     Services, the Administrator of the Agency for Healthcare 
     Research and Quality, the head of the Office of the National 
     Coordinator for Health Information Technology, and the 
     Secretary of Veterans Affairs, determine the best methods 
     for--
       ``(A) including in the registry, in a manner consistent 
     with subsection (f), appropriate information to identify each 
     covered device by type, model, and serial number or other 
     unique identifier;
       ``(B) validating methods for analyzing patient safety and 
     outcomes data from multiple sources and for linking such data 
     with the information included in the registry as described in 
     subparagraph (A), including, to the extent feasible, use of--
       ``(i) data provided to the Secretary under other provisions 
     of this chapter; and
       ``(ii) information from public and private sources 
     identified under paragraph (3);
       ``(C) integrating the activities described in this 
     subsection (so as to avoid duplication) with--

[[Page 27378]]

       ``(i) activities under paragraph (3) of section 505(k) 
     (relating to active postmarket risk identification);
       ``(ii) activities under paragraph (4) of section 505(k) 
     (relating to advanced analysis of drug safety data);
       ``(iii) other postmarket device surveillance activities of 
     the Secretary authorized by this chapter; and
       ``(iv) registries carried out by or for the Agency for 
     Healthcare Research and Quality; and
       ``(D) providing public access to the data and analysis 
     collected or developed through the registry in a manner and 
     form that protects patient privacy and proprietary 
     information and is comprehensive, useful, and not misleading 
     to patients, physicians, and scientists.
       ``(3)(A) To facilitate analyses of postmarket safety and 
     patient outcomes for covered devices, the Secretary shall, in 
     collaboration with public, academic, and private entities, 
     develop methods to--
       ``(i) obtain access to disparate sources of patient safety 
     and outcomes data, including--
       ``(I) Federal health-related electronic data (such as data 
     from the Medicare program under title XVIII of the Social 
     Security Act or from the health systems of the Department of 
     Veterans Affairs);
       ``(II) private sector health-related electronic data (such 
     as pharmaceutical purchase data and health insurance claims 
     data); and
       ``(III) other data as the Secretary deems necessary to 
     permit postmarket assessment of device safety and 
     effectiveness; and
       ``(ii) link data obtained under clause (i) with information 
     in the registry.
       ``(B) In this paragraph, the term `data' refers to 
     information respecting a covered device, including claims 
     data, patient survey data, standardized analytic files that 
     allow for the pooling and analysis of data from disparate 
     data environments, electronic health records, and any other 
     data deemed appropriate by the Secretary.
       ``(4) The Secretary shall promulgate regulations for 
     establishment and operation of the registry under paragraph 
     (1). Such regulations--
       ``(A)(i) in the case of covered devices that are sold on or 
     after the date of the enactment of this subsection, shall 
     require manufacturers of such devices to submit information 
     to the registry, including, for each such device, the type, 
     model, and serial number or, if required under subsection 
     (f), other unique device identifier; and
       ``(ii) in the case of covered devices that are sold before 
     such date, may require manufacturers of such devices to 
     submit such information to the registry, if deemed necessary 
     by the Secretary to protect the public health;
       ``(B) shall establish procedures--
       ``(i) to permit linkage of information submitted pursuant 
     to subparagraph (A) with patient safety and outcomes data 
     obtained under paragraph (3); and
       ``(ii) to permit analyses of linked data;
       ``(C) may require covered device manufacturers to submit 
     such other information as is necessary to facilitate 
     postmarket assessments of device safety and effectiveness and 
     notification of device risks;
       ``(D) shall establish requirements for regular and timely 
     reports to the Secretary, which shall be included in the 
     registry, concerning adverse event trends, adverse event 
     patterns, incidence and prevalence of adverse events, and 
     other information the Secretary determines appropriate, which 
     may include data on comparative safety and outcomes trends; 
     and
       ``(E) shall establish procedures to permit public access to 
     the information in the registry in a manner and form that 
     protects patient privacy and proprietary information and is 
     comprehensive, useful, and not misleading to patients, 
     physicians, and scientists.
       ``(5)(A) The Secretary shall promulgate final regulations 
     under paragraph (4) not later than 36 months after the date 
     of the enactment of this subsection.
       ``(B) Before issuing the notice of proposed rulemaking 
     preceding the final regulations described in subparagraph 
     (A), the Secretary shall hold a public hearing before an 
     advisory committee on the issue of which class II devices to 
     include in the definition of covered devices.
       ``(C) The Secretary shall include in any regulation under 
     this subsection an explanation demonstrating that the 
     requirements of such regulation--
       ``(i) do not duplicate other Federal requirements; and
       ``(ii) do not impose an undue burden on device 
     manufacturers.
       ``(6) With respect to any entity that submits or is 
     required to submit a safety report or other information in 
     connection with the safety of a device under this section 
     (and any release by the Secretary of that report or 
     information), such report or information shall not be 
     construed to reflect necessarily a conclusion by the entity 
     or the Secretary that the report or information constitutes 
     an admission that the product involved malfunctioned, caused 
     or contributed to an adverse experience, or otherwise caused 
     or contributed to a death, serious injury, or serious 
     illness. Such an entity need not admit, and may deny, that 
     the report or information submitted by the entity constitutes 
     an admission that the product involved malfunctioned, caused 
     or contributed to an adverse experience, or caused or 
     contributed to a death, serious injury, or serious illness.
       ``(7) To carry out this subsection, there are authorized to 
     be appropriated such sums as may be necessary for each of 
     fiscal years 2011 and 2012.''.
       (2) Effective date.--The Secretary of Health and Human 
     Services shall establish and begin implementation of the 
     registry under section 519(g) of the Federal Food, Drug, and 
     Cosmetic Act, as added by paragraph (1), by not later than 
     the date that is 36 months after the date of the enactment of 
     this Act, without regard to whether or not final regulations 
     to establish and operate the registry have been promulgated 
     by such date.
       (3) Conforming amendment.--Section 303(f)(1)(B)(ii) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
     333(f)(1)(B)(ii)) is amended by striking ``519(g)'' and 
     inserting ``519(h)''.
       (b) Electronic Exchange and Use in Certified Electronic 
     Health Records of Unique Device Identifiers.--
       (1) Recommendations.--The HIT Policy Committee established 
     under section 3002 of the Public Health Service Act (42 
     U.S.C. 300jj-12) shall recommend to the head of the Office of 
     the National Coordinator for Health Information Technology 
     standards, implementation specifications, and certification 
     criteria for the electronic exchange and use in certified 
     electronic health records of a unique device identifier for 
     each covered device (as defined under section 519(g)(1)(B) of 
     the Federal Food, Drug, and Cosmetic Act, as added by 
     subsection (a)).
       (2) Standards, implementation criteria, and certification 
     criteria.--The Secretary of Health and Human Services, acting 
     through the head of the Office of the National Coordinator 
     for Health Information Technology, shall adopt standards, 
     implementation specifications, and certification criteria for 
     the electronic exchange and use in certified electronic 
     health records of a unique device identifier for each covered 
     device referred to in paragraph (1), if such an identifier is 
     required by section 519(f) of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 360i(f)) for the device.
       (c) Unique Device Identification System.--The Secretary of 
     Health and Human Services, acting through the Commissioner of 
     Food and Drugs, shall issue proposed regulations to implement 
     section 519(f) of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 360i(f)) not later than 6 months after the date of 
     the enactment of this Act.

     SEC. 2572. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN 
                   RESTAURANTS AND OF ARTICLES OF FOOD SOLD FROM 
                   VENDING MACHINES.

       (a) Technical Amendments.--Section 403(q)(5)(A) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) 
     is amended--
       (1) in subclause (i), by inserting ``except as provided in 
     clause (H)(ii)(III),'' after ``(i)'' ; and
       (2) in subclause (ii), by inserting ``except as provided in 
     clause (H)(ii)(III),'' after ``(ii)''.
       (b) Labeling Requirements.--Section 403(q)(5) of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is 
     amended by adding at the end the following:
       ``(H) Restaurants, Retail Food Establishments, and Vending 
     Machines.--
       ``(i) General requirements for restaurants and similar 
     retail food establishments.--Except for food described in 
     subclause (vii), in the case of food that is a standard menu 
     item that is offered for sale in a restaurant or similar 
     retail food establishment that is part of a chain with 20 or 
     more locations doing business under the same name (regardless 
     of the type of ownership of the locations) and offering for 
     sale substantially the same menu items, the restaurant or 
     similar retail food establishment shall disclose the 
     information described in subclauses (ii) and (iii).
       ``(ii) Information required to be disclosed by restaurants 
     and retail food establishments.--Except as provided in 
     subclause (vii), the restaurant or similar retail food 
     establishment shall disclose in a clear and conspicuous 
     manner--
       ``(I)(aa) in a nutrient content disclosure statement 
     adjacent to the name of the standard menu item, so as to be 
     clearly associated with the standard menu item, on the menu 
     listing the item for sale, the number of calories contained 
     in the standard menu item, as usually prepared and offered 
     for sale; and
       ``(bb) a succinct statement concerning suggested daily 
     caloric intake, as specified by the Secretary by regulation 
     and posted prominently on the menu and designed to enable the 
     public to understand, in the context of a total daily diet, 
     the significance of the caloric information that is provided 
     on the menu;
       ``(II)(aa) in a nutrient content disclosure statement 
     adjacent to the name of the standard menu item, so as to be 
     clearly associated with the standard menu item, on the menu 
     board, including a drive-through menu board, the number of 
     calories contained in the standard menu item, as usually 
     prepared and offered for sale; and

[[Page 27379]]

       ``(bb) a succinct statement concerning suggested daily 
     caloric intake, as specified by the Secretary by regulation 
     and posted prominently on the menu board, designed to enable 
     the public to understand, in the context of a total daily 
     diet, the significance of the nutrition information that is 
     provided on the menu board;
       ``(III) in a written form, available on the premises of the 
     restaurant or similar retail establishment and to the 
     consumer upon request, the nutrition information required 
     under clauses (C) and (D) of subparagraph (1); and
       ``(IV) on the menu or menu board, a prominent, clear, and 
     conspicuous statement regarding the availability of the 
     information described in item (III).
       ``(iii) Self-service food and food on display.--Except as 
     provided in subclause (vii), in the case of food sold at a 
     salad bar, buffet line, cafeteria line, or similar self-
     service facility, and for self-service beverages or food that 
     is on display and that is visible to customers, a restaurant 
     or similar retail food establishment shall place adjacent to 
     each food offered a sign that lists calories per displayed 
     food item or per serving.
       ``(iv) Reasonable basis.--For the purposes of this clause, 
     a restaurant or similar retail food establishment shall have 
     a reasonable basis for its nutrient content disclosures, 
     including nutrient databases, cookbooks, laboratory analyses, 
     and other reasonable means, as described in section 101.10 of 
     title 21, Code of Federal Regulations (or any successor 
     regulation) or in a related guidance of the Food and Drug 
     Administration.
       ``(v) Menu variability and combination meals.--The 
     Secretary shall establish by regulation standards for 
     determining and disclosing the nutrient content for standard 
     menu items that come in different flavors, varieties, or 
     combinations, but which are listed as a single menu item, 
     such as soft drinks, ice cream, pizza, doughnuts, or 
     children's combination meals, through means determined by the 
     Secretary, including ranges, averages, or other methods.
       ``(vi) Additional information.--If the Secretary determines 
     that a nutrient, other than a nutrient required under 
     subclause (ii)(III), should be disclosed for the purpose of 
     providing information to assist consumers in maintaining 
     healthy dietary practices, the Secretary may require, by 
     regulation, disclosure of such nutrient in the written form 
     required under subclause (ii)(III).
       ``(vii) Nonapplicability to certain food.--
       ``(I) In general.--Subclauses (i) through (vi) do not apply 
     to--
       ``(aa) items that are not listed on a menu or menu board 
     (such as condiments and other items placed on the table or 
     counter for general use);
       ``(bb) daily specials, temporary menu items appearing on 
     the menu for less than 60 days per calendar year, or custom 
     orders; or
       ``(cc) such other food that is part of a customary market 
     test appearing on the menu for less than 90 days, under terms 
     and conditions established by the Secretary.
       ``(II) Written forms.--Clause (C) shall apply to any 
     regulations promulgated under subclauses (ii)(III) and (vi).
       ``(viii) Vending machines.--In the case of an article of 
     food sold from a vending machine that--
       ``(I) does not permit a prospective purchaser to examine 
     the Nutrition Facts Panel before purchasing the article or 
     does not otherwise provide visible nutrition information at 
     the point of purchase; and
       ``(II) is operated by a person who is engaged in the 
     business of owning or operating 20 or more vending machines,
     the vending machine operator shall provide a sign in close 
     proximity to each article of food or the selection button 
     that includes a clear and conspicuous statement disclosing 
     the number of calories contained in the article.
       ``(ix) Voluntary provision of nutrition information.--
       ``(I) In general.--An authorized official of any restaurant 
     or similar retail food establishment or vending machine 
     operator not subject to the requirements of this clause may 
     elect to be subject to the requirements of such clause, by 
     registering biannually the name and address of such 
     restaurant or similar retail food establishment or vending 
     machine operator with the Secretary, as specified by the 
     Secretary by regulation.
       ``(II) Registration.--Within 120 days of the enactment of 
     this clause, the Secretary shall publish a notice in the 
     Federal Register specifying the terms and conditions for 
     implementation of item (I), pending promulgation of 
     regulations.
       ``(III) Rule of construction.--Nothing in this subclause 
     shall be construed to authorize the Secretary to require an 
     application, review, or licensing process for any entity to 
     register with the Secretary, as described in such item.
       ``(x) Regulations.--
       ``(I) Proposed regulation.--Not later than 1 year after the 
     date of the enactment of this clause, the Secretary shall 
     promulgate proposed regulations to carry out this clause.
       ``(II) Contents.--In promulgating regulations, the 
     Secretary shall--
       ``(aa) consider standardization of recipes and methods of 
     preparation, reasonable variation in serving size and 
     formulation of menu items, space on menus and menu boards, 
     inadvertent human error, training of food service workers, 
     variations in ingredients, and other factors, as the 
     Secretary determines; and
       ``(bb) specify the format and manner of the nutrient 
     content disclosure requirements under this subclause.
       ``(III) Reporting.--The Secretary shall submit to the 
     Committee on Health, Education, Labor, and Pensions of the 
     Senate and the Committee on Energy and Commerce of the House 
     of Representatives a quarterly report that describes the 
     Secretary's progress toward promulgating final regulations 
     under this subparagraph.
       ``(xi) Definition.--In this clause, the term `menu' or 
     `menu board' means the primary writing of the restaurant or 
     other similar retail food establishment from which a consumer 
     makes an order selection.''.
       (c) National Uniformity.--Section 403A(a)(4) of the Federal 
     Food, Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is 
     amended by striking ``except a requirement for nutrition 
     labeling of food which is exempt under subclause (i) or (ii) 
     of section 403(q)(5)(A)'' and inserting ``except that this 
     paragraph does not apply to food that is offered for sale in 
     a restaurant or similar retail food establishment that is not 
     part of a chain with 20 or more locations doing business 
     under the same name (regardless of the type of ownership of 
     the locations) and offering for sale substantially the same 
     menu items unless such restaurant or similar retail food 
     establishment complies with the voluntary provision of 
     nutrition information requirements under section 
     403(q)(5)(H)(ix)''.
       (d) Rule of Construction.--Nothing in the amendments made 
     by this section shall be construed--
       (1) to preempt any provision of State or local law, unless 
     such provision establishes or continues into effect nutrient 
     content disclosures of the type required under section 
     403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as 
     added by subsection (b)) and is expressly preempted under 
     section 403A(a)(4) of such Act;
       (2) to apply to any State or local requirement respecting a 
     statement in the labeling of food that provides for a warning 
     concerning the safety of the food or component of the food; 
     or
       (3) except as provided in section 403(q)(5)(H)(ix) of the 
     Federal Food, Drug, and Cosmetic Act (as added by subsection 
     (b)), to apply to any restaurant or similar retail food 
     establishment other than a restaurant or similar retail food 
     establishment described in section 403(q)(5)(H)(i) of such 
     Act.

     SEC. 2573. PROTECTING CONSUMER ACCESS TO GENERIC DRUGS.

       (a) Findings; Purpose.--
       (1) Findings.--The Congress finds the following:
       (A) In 1984, the Drug Price Competition and Patent Term 
     Restoration Act (Pub. L. 98-417; in this subsection referred 
     to as the ``1984 Act'') was enacted with the intent of 
     facilitating the early entry of generic drugs while 
     preserving incentives for innovation.
       (B) Prescription drugs make up 10 percent of national 
     health care spending, but for the past decade have been one 
     of the fastest growing segments of health care expenditures.
       (C) Until recently, the 1984 Act was successful in 
     facilitating generic competition to the benefit of consumers 
     and health care payers--although 67 percent of all 
     prescriptions dispensed in the United States are generic 
     drugs, they account for only 20 percent of all expenditures.
       (D) In recent years, the intent of the 1984 Act has been 
     subverted by certain settlement agreements between brand 
     companies and their potential generic competitors that make 
     reverse payments, i.e., payments by the brand company to the 
     generic company.
       (E) These settlement agreements have unduly delayed the 
     marketing of low-cost generic drugs contrary to free 
     competition and the interests of consumers.
       (F) The state of antitrust law relating to such settlement 
     agreements is unsettled.
       (2) Purpose.--The purpose of this section is to provide an 
     additional means to effectuate the intent of the 1984 Act by 
     enhancing competition in the pharmaceutical market by 
     stopping agreements between brand name and generic drug 
     manufacturers that limit, delay, or otherwise prevent 
     competition from generic drugs.
       (b) In General.--Section 505 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355) is amended by adding at the end 
     the following:
       ``(w) Protecting Consumer Access to Generic Drugs.--
       ``(1) Unfair and deceptive acts and practices related to 
     new drug applications.--
       ``(A) Conduct prohibited.--It shall be unlawful for any 
     person to directly or indirectly be a party to any agreement 
     resolving or settling a patent infringement claim in which--
       ``(i) an ANDA filer receives anything of value; and
       ``(ii) the ANDA filer agrees to limit or forego research, 
     development, manufacturing, marketing, or sales, for any 
     period of time, of the drug that is to be manufactured under 
     the ANDA involved and is the subject of the patent 
     infringement claim.

[[Page 27380]]

       ``(B) Exceptions.--Notwithstanding subparagraph (A)(i), 
     subparagraph (A) does not prohibit a resolution or settlement 
     of a patent infringement claim in which the value received by 
     the ANDA filer includes no more than--
       ``(i) the right to market the drug that is to be 
     manufactured under the ANDA involved and is the subject of 
     the patent infringement claim, before the expiration of--

       ``(I) the patent that is the basis for the patent 
     infringement claim; or
       ``(II) any other statutory exclusivity that would prevent 
     the marketing of such drug; and

       ``(ii) the waiver of a patent infringement claim for 
     damages based on prior marketing of such drug.
       ``(C) Enforcement.--
       ``(i) In general.--A violation of subparagraph (A) shall be 
     treated as an unfair and deceptive act or practice and an 
     unfair method of competition in or affecting interstate 
     commerce prohibited under section 5 of the Federal Trade 
     Commission Act and shall be enforced by the Federal Trade 
     Commission in the same manner, by the same means, and with 
     the same jurisdiction as though all applicable terms and 
     provisions of the Federal Trade Commission Act were 
     incorporated into and made a part of this subsection.
       ``(ii) Inapplicability.--Subchapter A of chapter VII shall 
     not apply with respect to this subsection.
       ``(D) Definitions.--In this subsection:
       ``(i) Agreement.--The term `agreement' means anything that 
     would constitute an agreement under section 5 of the Federal 
     Trade Commission Act.
       ``(ii) Agreement resolving or settling.--The term 
     `agreement resolving or settling', in reference to a patent 
     infringement claim, includes any agreement that is contingent 
     upon, provides a contingent condition for, or is otherwise 
     related to the resolution or settlement of the claim.
       ``(iii) ANDA.--The term `ANDA' means an abbreviated new 
     drug application for the approval of a new drug under section 
     (j).
       ``(iv) ANDA filer.--The term `ANDA filer' means a party 
     that has filed an ANDA with the Food and Drug Administration.
       ``(v) Patent infringement.--The term `patent infringement' 
     means infringement of any patent or of any filed patent 
     application, extension, reissuance, renewal, division, 
     continuation, continuation in part, reexamination, patent 
     term restoration, patent of addition, or extension thereof.
       ``(vi) Patent infringement claim.--The term `patent 
     infringement claim' means any allegation made to an ANDA 
     filer, whether or not included in a complaint filed with a 
     court of law, that its ANDA or drug to be manufactured under 
     such ANDA may infringe any patent.
       ``(2) FTC rulemaking.--The Federal Trade Commission may, by 
     rule promulgated under section 553 of title 5, United States 
     Code, exempt certain agreements described in paragraph (1) 
     from the requirements of this subsection if the Commission 
     finds such agreements to be in furtherance of market 
     competition and for the benefit of consumers. Consistent with 
     the authority of the Commission, such rules may include 
     interpretive rules and general statements of policy with 
     respect to the practices prohibited under paragraph (1).''.
       (c) Notice and Certification of Agreements.--
       (1) Notice of all agreements.--Section 1112(c)(2) of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 (21 U.S.C. 3155 note) is amended by--
       (A) striking ``the Commission the'' and inserting the 
     following: ``the Commission--
       ``(A) the'';
       (B) striking the period at the end and inserting ``; and''; 
     and
       (C) adding at the end the following:
       ``(B) any other agreement the parties enter into within 30 
     days of entering into an agreement covered by subsection (a) 
     or (b).''.
       (2) Certification of agreements.--Section 1112 of such Act 
     is amended by adding at the end the following:
       ``(d) Certification.--The chief executive officer or the 
     company official responsible for negotiating any agreement 
     required to be filed under subsection (a), (b), or (c) shall 
     execute and file with the Assistant Attorney General and the 
     Commission a certification as follows: `I declare under 
     penalty of perjury that the following is true and correct: 
     The materials filed with the Federal Trade Commission and the 
     Department of Justice under section 1112 of subtitle B of 
     title XI of the Medicare Prescription Drug, Improvement, and 
     Modernization Act of 2003, with respect to the agreement 
     referenced in this certification: (1) represent the complete, 
     final, and exclusive agreement between the parties; (2) 
     include any ancillary agreements that are contingent upon, 
     provide a contingent condition for, or are otherwise related 
     to, the referenced agreement; and (3) include written 
     descriptions of any oral agreements, representations, 
     commitments, or promises between the parties that are 
     responsive to subsection (a) or (b) of such section 1112 and 
     have not been reduced to writing.'.''.
       (d) GAO Study.--
       (1) Study.--Beginning 2 years after the date of enactment 
     of this Act, and each year for a period of 4 years 
     thereafter, the Comptroller General shall conduct a study on 
     the litigation in United States courts during the period 
     beginning 5 years prior to the date of enactment of this Act 
     relating to patent infringement claims involving generic 
     drugs, the number of patent challenges initiated by 
     manufacturers of generic drugs, and the number of settlements 
     of such litigation. The Comptroller General shall transmit to 
     Congress a report of the findings of such a study and an 
     analysis of the effect of the amendments made by subsections 
     (b) and (c) on such litigation, whether such amendments have 
     had an effect on the number and frequency of claims settled, 
     and whether such amendments resulted in earlier or delayed 
     entry of generic drugs to market, including whether any harm 
     or benefit to consumers has resulted.
       (2) Disclosure of agreements.--Notwithstanding any other 
     law, agreements filed under section 1112 of the Medicare 
     Prescription Drug, Improvement, and Modernization Act of 2003 
     (21 U.S.C. 355 note), or unaggregated information from such 
     agreements, shall be disclosed to the Comptroller General for 
     purposes of the study under paragraph (1) within 30 days of a 
     request by the Comptroller General.

                          PART 2--BIOSIMILARS

     SEC. 2575. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL 
                   PRODUCTS.

       (a) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--Section 351 of the Public Health Service 
     Act (42 U.S.C. 262) is amended--
       (1) in subsection (a)(1)(A), by inserting ``under this 
     subsection or subsection (k)'' after ``biologics license''; 
     and
       (2) by adding at the end the following:
       ``(k) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--
       ``(1) In general.--Any person may submit an application for 
     licensure of a biological product under this subsection.
       ``(2) Content.--
       ``(A) In general.--
       ``(i) Required information.--An application submitted under 
     this subsection shall include information demonstrating 
     that--

       ``(I) the biological product is biosimilar to a reference 
     product based upon data derived from--

       ``(aa) analytical studies that demonstrate that the 
     biological product is highly similar to the reference product 
     notwithstanding minor differences in clinically inactive 
     components;
       ``(bb) animal studies (including the assessment of 
     toxicity); and
       ``(cc) a clinical study or studies (including the 
     assessment of immunogenicity and pharmacokinetics or 
     pharmacodynamics) that are sufficient to demonstrate safety, 
     purity, and potency in 1 or more appropriate conditions of 
     use for which the reference product is licensed and intended 
     to be used and for which licensure is sought for the 
     biological product;

       ``(II) the biological product and reference product utilize 
     the same mechanism or mechanisms of action for the condition 
     or conditions of use prescribed, recommended, or suggested in 
     the proposed labeling, but only to the extent the mechanism 
     or mechanisms of action are known for the reference product;
       ``(III) the condition or conditions of use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     biological product have been previously approved for the 
     reference product;
       ``(IV) the route of administration, the dosage form, and 
     the strength of the biological product are the same as those 
     of the reference product; and
       ``(V) the facility in which the biological product is 
     manufactured, processed, packed, or held meets standards 
     designed to assure that the biological product continues to 
     be safe, pure, and potent.

       ``(ii) Determination by secretary.--The Secretary may 
     determine, in the Secretary's discretion, that an element 
     described in clause (i)(I) is unnecessary in an application 
     submitted under this subsection.
       ``(iii) Additional information.--An application submitted 
     under this subsection--

       ``(I) shall include publicly available information 
     regarding the Secretary's previous determination that the 
     reference product is safe, pure, and potent; and
       ``(II) may include any additional information in support of 
     the application, including publicly available information 
     with respect to the reference product or another biological 
     product.

       ``(B) Interchangeability.--An application (or a supplement 
     to an application) submitted under this subsection may 
     include information demonstrating that the biological product 
     meets the standards described in paragraph (4).
       ``(3) Evaluation by secretary.--Upon review of an 
     application (or a supplement to an application) submitted 
     under this subsection, the Secretary shall license the 
     biological product under this subsection if--
       ``(A) the Secretary determines that the information 
     submitted in the application (or the supplement) is 
     sufficient to show that the biological product--
       ``(i) is biosimilar to the reference product; or
       ``(ii) meets the standards described in paragraph (4), and 
     therefore is interchangeable with the reference product; and

[[Page 27381]]

       ``(B) the applicant (or other appropriate person) consents 
     to the inspection of the facility that is the subject of the 
     application, in accordance with subsection (c).
       ``(4) Safety standards for determining 
     interchangeability.--Upon review of an application submitted 
     under this subsection or any supplement to such application, 
     the Secretary shall determine the biological product to be 
     interchangeable with the reference product if the Secretary 
     determines that the information submitted in the application 
     (or a supplement to such application) is sufficient to show 
     that--
       ``(A) the biological product--
       ``(i) is biosimilar to the reference product; and
       ``(ii) can be expected to produce the same clinical result 
     as the reference product in any given patient; and
       ``(B) for a biological product that is administered more 
     than once to an individual, the risk in terms of safety or 
     diminished efficacy of alternating or switching between use 
     of the biological product and the reference product is not 
     greater than the risk of using the reference product without 
     such alternation or switch.
       ``(5) General rules.--
       ``(A) One reference product per application.--A biological 
     product, in an application submitted under this subsection, 
     may not be evaluated against more than 1 reference product.
       ``(B) Review.--An application submitted under this 
     subsection shall be reviewed by the division within the Food 
     and Drug Administration that is responsible for the review 
     and approval of the application under which the reference 
     product is licensed.
       ``(C) Risk evaluation and mitigation strategies.--The 
     authority of the Secretary with respect to risk evaluation 
     and mitigation strategies under the Federal Food, Drug, and 
     Cosmetic Act shall apply to biological products licensed 
     under this subsection in the same manner as such authority 
     applies to biological products licensed under subsection (a).
       ``(D) Restrictions on biological products containing 
     dangerous ingredients.--If information in an application 
     submitted under this subsection, in a supplement to such an 
     application, or otherwise available to the Secretary shows 
     that a biological product--
       ``(i) is, bears, or contains a select agent or toxin listed 
     in section 73.3 or 73.4 of title 42, section 121.3 or 121.4 
     of title 9, or section 331.3 of title 7, Code of Federal 
     Regulations (or any successor regulations); or
       ``(ii) is, bears, or contains a controlled substance in 
     schedule I or II of section 202 of the Controlled Substances 
     Act, as listed in part 1308 of title 21, Code of Federal 
     Regulations (or any successor regulations);
     the Secretary shall not license the biological product under 
     this subsection unless the Secretary determines, after 
     consultation with appropriate national security and drug 
     enforcement agencies, that there would be no increased risk 
     to the security or health of the public from licensing such 
     biological product under this subsection.
       ``(6) Exclusivity for first interchangeable biological 
     product.--Upon review of an application submitted under this 
     subsection relying on the same reference product for which a 
     prior biological product has received a determination of 
     interchangeability for any condition of use, the Secretary 
     shall not make a determination under paragraph (4) that the 
     second or subsequent biological product is interchangeable 
     for any condition of use until the earlier of--
       ``(A) 1 year after the first commercial marketing of the 
     first interchangeable biosimilar biological product to be 
     approved as interchangeable for that reference product;
       ``(B) 18 months after--
       ``(i) a final court decision on all patents in suit in an 
     action instituted under subsection (l)(5) against the 
     applicant that submitted the application for the first 
     approved interchangeable biosimilar biological product; or
       ``(ii) the dismissal with or without prejudice of an action 
     instituted under subsection (l)(5) against the applicant that 
     submitted the application for the first approved 
     interchangeable biosimilar biological product; or
       ``(C)(i) 42 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has been sued under 
     subsection (l)(5) and such litigation is still ongoing within 
     such 42-month period; or
       ``(ii) 18 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has not been sued 
     under subsection (l)(5).

     For purposes of this paragraph, the term `final court 
     decision' means a final decision of a court from which no 
     appeal (other than a petition to the United States Supreme 
     Court for a writ of certiorari) has been or can be taken.
       ``(7) Exclusivity for reference product.--
       ``(A) Effective date of biosimilar application approval.--
     Approval of an application under this subsection may not be 
     made effective by the Secretary until the date that is 12 
     years after the date on which the reference product was first 
     licensed under subsection (a).
       ``(B) Filing period.--An application under this subsection 
     may not be submitted to the Secretary until the date that is 
     4 years after the date on which the reference product was 
     first licensed under subsection (a).
       ``(C) First licensure.--Subparagraphs (A) and (B) shall not 
     apply to a license for or approval of--
       ``(i) a supplement for the biological product that is the 
     reference product; or
       ``(ii) a subsequent application filed by the same sponsor 
     or manufacturer of the biological product that is the 
     reference product (or a licensor, predecessor in interest, or 
     other related entity) for--

       ``(I) a change (not including a modification to the 
     structure of the biological product) that results in a new 
     indication, route of administration, dosing schedule, dosage 
     form, delivery system, delivery device, or strength; or
       ``(II) a modification to the structure of the biological 
     product that does not result in a change in safety, purity, 
     or potency.

       ``(8) Pediatric studies.--
       ``(A) Exclusivity.--If, before or after licensure of the 
     reference product under subsection (a) of this section, the 
     Secretary determines that information relating to the use of 
     such product in the pediatric population may produce health 
     benefits in that population, the Secretary makes a written 
     request for pediatric studies (which shall include a 
     timeframe for completing such studies), the applicant or 
     holder of the approved application agrees to the request, 
     such studies are completed using appropriate formulations for 
     each age group for which the study is requested within any 
     such timeframe, and the reports thereof are submitted and 
     accepted in accordance with section 505A(d)(3) of the Federal 
     Food, Drug, and Cosmetic Act the period referred to in 
     paragraph (7)(A) of this subsection is deemed to be 12 years 
     and 6 months rather than 12 years.
       ``(B) Exception.--The Secretary shall not extend the period 
     referred to in subparagraph (A) of this paragraph if the 
     determination under section 505A(d)(3) of the Federal Food, 
     Drug, and Cosmetic Act is made later than 9 months prior to 
     the expiration of such period.
       ``(C) Application of certain provisions.--The provisions of 
     subsections (a), (d), (e), (f), (h), (j), (k), and (l) of 
     section 505A of the Federal Food, Drug, and Cosmetic Act 
     shall apply with respect to the extension of a period under 
     subparagraph (A) of this paragraph to the same extent and in 
     the same manner as such provisions apply with respect to the 
     extension of a period under subsection (b) or (c) of section 
     505A of the Federal Food, Drug, and Cosmetic Act.
       ``(9) Guidance documents.--
       ``(A) In general.--The Secretary may, after opportunity for 
     public comment, issue guidance in accordance, except as 
     provided in subparagraph (B)(i), with section 701(h) of the 
     Federal Food, Drug, and Cosmetic Act with respect to the 
     licensure of a biological product under this subsection. Any 
     such guidance may be general or specific.
       ``(B) Public comment.--
       ``(i) In general.--The Secretary shall provide the public 
     an opportunity to comment on any proposed guidance issued 
     under subparagraph (A) before issuing final guidance.
       ``(ii) Input regarding most valuable guidance.--The 
     Secretary shall establish a process through which the public 
     may provide the Secretary with input regarding priorities for 
     issuing guidance.
       ``(C) No requirement for application consideration.--The 
     issuance (or non-issuance) of guidance under subparagraph (A) 
     shall not preclude the review of, or action on, an 
     application submitted under this subsection.
       ``(D) Requirement for product class-specific guidance.--If 
     the Secretary issues product class-specific guidance under 
     subparagraph (A), such guidance shall include a description 
     of--
       ``(i) the criteria that the Secretary will use to determine 
     whether a biological product is highly similar to a reference 
     product in such product class; and
       ``(ii) the criteria, if available, that the Secretary will 
     use to determine whether a biological product meets the 
     standards described in paragraph (4).
       ``(E) Certain product classes.--
       ``(i) Guidance.--The Secretary may indicate in a guidance 
     document that the science and experience, as of the date of 
     such guidance, with respect to a product or product class 
     (not including any recombinant protein) does not allow 
     approval of an application for a license as provided under 
     this subsection for such product or product class.
       ``(ii) Modification or reversal.--The Secretary may issue a 
     subsequent guidance document under subparagraph (A) to modify 
     or reverse a guidance document under clause (i).
       ``(iii) No effect on ability to deny license.--Clause (i) 
     shall not be construed to require the Secretary to approve a 
     product with respect to which the Secretary has not indicated 
     in a guidance document that the science and experience, as 
     described in clause (i), does not allow approval of such an 
     application.
       ``(10) Naming.--The Secretary shall ensure that the 
     labeling and packaging of each biological product licensed 
     under this subsection bears a name that uniquely identifies 
     the biological product and distinguishes it

[[Page 27382]]

     from the reference product and any other biological products 
     licensed under this subsection following evaluation against 
     such reference product.
       ``(l) Patent Notices; Relationship to Final Approval.--
       ``(1) Definitions.--For the purposes of this subsection, 
     the term--
       ``(A) `biosimilar product' means the biological product 
     that is the subject of the application under subsection (k);
       ``(B) `relevant patent' means a patent that--
       ``(i) expires after the date specified in subsection 
     (k)(7)(A) that applies to the reference product; and
       ``(ii) could reasonably be asserted against the applicant 
     due to the unauthorized making, use, sale, or offer for sale 
     within the United States, or the importation into the United 
     States of the biosimilar product, or materials used in the 
     manufacture of the biosimilar product, or due to a use of the 
     biosimilar product in a method of treatment that is indicated 
     in the application;
       ``(C) `reference product sponsor' means the holder of an 
     approved application or license for the reference product; 
     and
       ``(D) `interested third party' means a person other than 
     the reference product sponsor that owns a relevant patent, or 
     has the right to commence or participate in an action for 
     infringement of a relevant patent.
       ``(2) Handling of confidential information.--Any entity 
     receiving confidential information pursuant to this 
     subsection shall designate one or more individuals to receive 
     such information. Each individual so designated shall execute 
     an agreement in accordance with regulations promulgated by 
     the Secretary. The regulations shall require each such 
     individual to take reasonable steps to maintain the 
     confidentiality of information received pursuant to this 
     subsection and use the information solely for purposes 
     authorized by this subsection. The obligations imposed on an 
     individual who has received confidential information pursuant 
     to this subsection shall continue until the individual 
     returns or destroys the confidential information, a court 
     imposes a protective order that governs the use or handling 
     of the confidential information, or the party providing the 
     confidential information agrees to other terms or conditions 
     regarding the handling or use of the confidential 
     information.
       ``(3) Public notice by secretary.--Within 30 days of 
     acceptance by the Secretary of an application filed under 
     subsection (k), the Secretary shall publish a notice 
     identifying--
       ``(A) the reference product identified in the application; 
     and
       ``(B) the name and address of an agent designated by the 
     applicant to receive notices pursuant to paragraph (4)(B).
       ``(4) Exchanges concerning patents.--
       ``(A) Exchanges with reference product sponsor.--
       ``(i) Within 30 days of the date of acceptance of the 
     application by the Secretary, the applicant shall provide the 
     reference product sponsor with a copy of the application and 
     information concerning the biosimilar product and its 
     production. This information shall include a detailed 
     description of the biosimilar product, its method of 
     manufacture, and the materials used in the manufacture of the 
     product.
       ``(ii) Within 60 days of the date of receipt of the 
     information required to be provided under clause (i), the 
     reference product sponsor shall provide to the applicant a 
     list of relevant patents owned by the reference product 
     sponsor, or in respect of which the reference product sponsor 
     has the right to commence an action of infringement or 
     otherwise has an interest in the patent as such patent 
     concerns the biosimilar product.
       ``(iii) If the reference product sponsor is issued or 
     acquires an interest in a relevant patent after the date on 
     which the reference product sponsor provides the list 
     required by clause (ii) to the applicant, the reference 
     product sponsor shall identify that patent to the applicant 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(B) Exchanges with interested third parties.--
       ``(i) At any time after the date on which the Secretary 
     publishes a notice for an application under paragraph (3), 
     any interested third party may provide notice to the 
     designated agent of the applicant that the interested third 
     party owns or has rights under 1 or more patents that may be 
     relevant patents. The notice shall identify at least 1 patent 
     and shall designate an individual who has executed an 
     agreement in accordance with paragraph (2) to receive 
     confidential information from the applicant.
       ``(ii) Within 30 days of the date of receiving notice 
     pursuant to clause (i), the applicant shall send to the 
     individual designated by the interested third party the 
     information specified in subparagraph (A)(i), unless the 
     applicant and interested third party otherwise agree.
       ``(iii) Within 90 days of the date of receiving information 
     pursuant to clause (ii), the interested third party shall 
     provide to the applicant a list of relevant patents which the 
     interested third party owns, or in respect of which the 
     interested third party has the right to commence or 
     participate in an action for infringement.
       ``(iv) If the interested third party is issued or acquires 
     an interest in a relevant patent after the date on which the 
     interested third party provides the list required by clause 
     (iii), the interested third party shall identify that patent 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(C) Identification of basis for infringement.--For any 
     patent identified under clause (ii) or (iii) of subparagraph 
     (A) or under clause (iii) or (iv) of subparagraph (B), the 
     reference product sponsor or the interested third party, as 
     applicable--
       ``(i) shall explain in writing why the sponsor or the 
     interested third party believes the relevant patent would be 
     infringed by the making, use, sale, or offer for sale within 
     the United States, or importation into the United States, of 
     the biosimilar product or by a use of the biosimilar product 
     in treatment that is indicated in the application;
       ``(ii) may specify whether the relevant patent is available 
     for licensing; and
       ``(iii) shall specify the number and date of expiration of 
     the relevant patent.
       ``(D) Certification by applicant concerning identified 
     relevant patents.--Not later than 45 days after the date on 
     which a patent is identified under clause (ii) or (iii) of 
     subparagraph (A) or under clause (iii) or (iv) of 
     subparagraph (B), the applicant shall send a written 
     statement regarding each identified patent to the party that 
     identified the patent. Such statement shall either--
       ``(i) state that the applicant will not commence marketing 
     of the biosimilar product and has requested the Secretary to 
     not grant final approval of the application before the date 
     of expiration of the noticed patent; or
       ``(ii) provide a detailed written explanation setting forth 
     the reasons why the applicant believes--

       ``(I) the making, use, sale, or offer for sale within the 
     United States, or the importation into the United States, of 
     the biosimilar product, or the use of the biosimilar product 
     in a treatment indicated in the application, would not 
     infringe the patent; or
       ``(II) the patent is invalid or unenforceable.

       ``(5) Action for infringement involving reference product 
     sponsor.--If an action for infringement concerning a relevant 
     patent identified by the reference product sponsor under 
     clause (ii) or (iii) of paragraph (4)(A), or by an interested 
     third party under clause (iii) or (iv) of paragraph (4)(B), 
     is brought within 60 days of the date of receipt of a 
     statement under paragraph (4)(D)(ii), and the court in which 
     such action has been commenced determines the patent is 
     infringed prior to the date applicable under subsection 
     (k)(7)(A) or (k)(8), the Secretary shall make approval of the 
     application effective on the day after the date of expiration 
     of the patent that has been found to be infringed. If more 
     than one such patent is found to be infringed by the court, 
     the approval of the application shall be made effective on 
     the day after the date that the last such patent expires.
       ``(6) Notification of agreements.--
       ``(A) Requirements.--
       ``(i) Agreement between biosimilar product applicant and 
     reference product sponsor.--If a biosimilar product applicant 
     under subsection (k) and the reference product sponsor enter 
     into an agreement described in subparagraph (B), the 
     applicant and sponsor shall each file the agreement in 
     accordance with subparagraph (C).
       ``(ii) Agreement between biosimilar product applicants.--If 
     2 or more biosimilar product applicants submit an application 
     under subsection (k) for biosimilar products with the same 
     reference product and enter into an agreement described in 
     subparagraph (B), the applicants shall each file the 
     agreement in accordance with subparagraph (C).
       ``(B) Subject matter of agreement.--An agreement described 
     in this subparagraph--
       ``(i) is an agreement between the biosimilar product 
     applicant under subsection (k) and the reference product 
     sponsor or between 2 or more biosimilar product applicants 
     under subsection (k) regarding the manufacture, marketing, or 
     sale of--

       ``(I) the biosimilar product (or biosimilar products) for 
     which an application was submitted; or
       ``(II) the reference product;

       ``(ii) includes any agreement between the biosimilar 
     product applicant under subsection (k) and the reference 
     product sponsor or between 2 or more biosimilar product 
     applicants under subsection (k) that is contingent upon, 
     provides a contingent condition for, or otherwise relates to 
     an agreement described in clause (i); and
       ``(iii) excludes any agreement that solely concerns--

       ``(I) purchase orders for raw material supplies;
       ``(II) equipment and facility contracts;
       ``(III) employment or consulting contracts; or
       ``(IV) packaging and labeling contracts.

       ``(C) Filing.--
       ``(i) In general.--The text of an agreement required to be 
     filed by subparagraph (A) shall be filed with the Assistant 
     Attorney General and the Federal Trade Commission not later 
     than--

       ``(I) 10 business days after the date on which the 
     agreement is executed; and

[[Page 27383]]

       ``(II) prior to the date of the first commercial marketing 
     of, for agreements described in subparagraph (A)(i), the 
     biosimilar product that is the subject of the application or, 
     for agreements described in subparagraph (A)(ii), any 
     biosimilar product that is the subject of an application 
     described in such subparagraph.

       ``(ii) If agreement not reduced to text.--If an agreement 
     required to be filed by subparagraph (A) has not been reduced 
     to text, the persons required to file the agreement shall 
     each file written descriptions of the agreement that are 
     sufficient to disclose all the terms and conditions of the 
     agreement.
       ``(iii) Certification.--The chief executive officer or the 
     company official responsible for negotiating any agreement 
     required to be filed by subparagraph (A) shall include in any 
     filing under this paragraph a certification as follows: `I 
     declare under penalty of perjury that the following is true 
     and correct: The materials filed with the Federal Trade 
     Commission and the Department of Justice under section 
     351(l)(6) of the Public Health Service Act, with respect to 
     the agreement referenced in this certification: (1) represent 
     the complete, final, and exclusive agreement between the 
     parties; (2) include any ancillary agreements that are 
     contingent upon, provide a contingent condition for, or are 
     otherwise related to, the referenced agreement; and (3) 
     include written descriptions of any oral agreements, 
     representations, commitments, or promises between the parties 
     that are responsive to such section and have not been reduced 
     to writing.'.
       ``(D) Disclosure exemption.--Any information or documentary 
     material filed with the Assistant Attorney General or the 
     Federal Trade Commission pursuant to this paragraph shall be 
     exempt from disclosure under section 552 of title 5, United 
     States Code, and no such information or documentary material 
     may be made public, except as may be relevant to any 
     administrative or judicial action or proceeding. Nothing in 
     this subparagraph prevents disclosure of information or 
     documentary material to either body of the Congress or to any 
     duly authorized committee or subcommittee of the Congress.
       ``(E) Enforcement.--
       ``(i) Civil penalty.--Any person that violates a provision 
     of this paragraph shall be liable for a civil penalty of not 
     more than $11,000 for each day on which the violation occurs. 
     Such penalty may be recovered in a civil action--

       ``(I) brought by the United States; or
       ``(II) brought by the Federal Trade Commission in 
     accordance with the procedures established in section 
     16(a)(1) of the Federal Trade Commission Act.

       ``(ii) Compliance and equitable relief.--If any person 
     violates any provision of this paragraph, the United States 
     district court may order compliance, and may grant such other 
     equitable relief as the court in its discretion determines 
     necessary or appropriate, upon application of the Assistant 
     Attorney General or the Federal Trade Commission.
       ``(F) Rulemaking.--The Federal Trade Commission, with the 
     concurrence of the Assistant Attorney General and by rule in 
     accordance with section 553 of title 5, United States Code, 
     consistent with the purposes of this paragraph--
       ``(i) may define the terms used in this paragraph;
       ``(ii) may exempt classes of persons or agreements from the 
     requirements of this paragraph; and
       ``(iii) may prescribe such other rules as may be necessary 
     and appropriate to carry out the purposes of this paragraph.
       ``(G) Savings clause.--Any action taken by the Assistant 
     Attorney General or the Federal Trade Commission, or any 
     failure of the Assistant Attorney General or the Commission 
     to take action, under this paragraph shall not at any time 
     bar any proceeding or any action with respect to any 
     agreement between a biosimilar product applicant under 
     subsection (k) and the reference product sponsor, or any 
     agreement between biosimilar product applicants under 
     subsection (k), under any other provision of law, nor shall 
     any filing under this paragraph constitute or create a 
     presumption of any violation of any competition laws.''.
       (b) Definitions.--Section 351(i) of the Public Health 
     Service Act (42 U.S.C. 262(i)) is amended--
       (1) by striking ``In this section, the term `biological 
     product' means'' and inserting the following: ``In this 
     section:
       ``(1) The term `biological product' means'';
       (2) in paragraph (1), as so designated, by inserting 
     ``protein (except any chemically synthesized polypeptide),'' 
     after ``allergenic product,''; and
       (3) by adding at the end the following:
       ``(2) The term `biosimilar' or `biosimilarity', in 
     reference to a biological product that is the subject of an 
     application under subsection (k), means--
       ``(A) that the biological product is highly similar to the 
     reference product notwithstanding minor differences in 
     clinically inactive components; and
       ``(B) there are no clinically meaningful differences 
     between the biological product and the reference product in 
     terms of the safety, purity, and potency of the product.
       ``(3) The term `interchangeable' or `interchangeability', 
     in reference to a biological product that is shown to meet 
     the standards described in subsection (k)(4), means that the 
     biological product may be substituted for the reference 
     product without the intervention of the health care provider 
     who prescribed the reference product.
       ``(4) The term `reference product' means the single 
     biological product licensed under subsection (a) against 
     which a biological product is evaluated in an application 
     submitted under subsection (k).''.
       (c) Products Previously Approved Under Section 505.--
       (1) Requirement to follow section 351.--Except as provided 
     in paragraph (2), an application for a biological product 
     shall be submitted under section 351 of the Public Health 
     Service Act (42 U.S.C. 262) (as amended by this Act).
       (2) Exception.--An application for a biological product may 
     be submitted under section 505 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355) if--
       (A) such biological product is in a product class for which 
     a biological product in such product class is the subject of 
     an application approved under such section 505 not later than 
     the date of enactment of this Act; and
       (B) such application--
       (i) has been submitted to the Secretary of Health and Human 
     Services (referred to in this Act as the ``Secretary'') 
     before the date of enactment of this Act; or
       (ii) is submitted to the Secretary not later than the date 
     that is 10 years after the date of enactment of this Act.
       (3) Limitation.--Notwithstanding paragraph (2), an 
     application for a biological product may not be submitted 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355) if there is another biological product 
     approved under subsection (a) of section 351 of the Public 
     Health Service Act that could be a reference product with 
     respect to such application (within the meaning of such 
     section 351) if such application were submitted under 
     subsection (k) of such section 351.
       (4) Deemed approved under section 351.--An approved 
     application for a biological product under section 505 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 
     deemed to be a license for the biological product under such 
     section 351 on the date that is 10 years after the date of 
     enactment of this Act.
       (5) Definitions.--For purposes of this subsection, the term 
     ``biological product'' has the meaning given such term under 
     section 351 of the Public Health Service Act (42 U.S.C. 262) 
     (as amended by this Act).

     SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

       Subparagraph (B) of section 735(1) of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is amended by 
     inserting ``, including licensure of a biological product 
     under section 351(k) of such Act'' before the period at the 
     end.

     SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

       (a) Section 271(e)(2) of title 35, United States Code is 
     amended--
       (1) in subparagraph (A), by striking ``or'' after 
     ``patent,'';
       (2) in subparagraph (B), by adding ``or'' after the comma 
     at the end;
       (3) by inserting the following after subparagraph (B):
       ``(C) a statement under section 351(l)(4)(D)(ii) of the 
     Public Health Service Act,''; and
       (4) in the matter following subparagraph (C) (as added by 
     paragraph (3)), by inserting before the period the following: 
     ``, or if the statement described in subparagraph (C) is 
     provided in connection with an application to obtain a 
     license to engage in the commercial manufacture, use, or sale 
     of a biological product claimed in a patent or the use of 
     which is claimed in a patent before the expiration of such 
     patent''.
       (b) Section 271(e)(4) of title 35, United States Code, is 
     amended by striking ``in paragraph (2)'' in both places it 
     appears and inserting ``in paragraph (2)(A) or (2)(B)''.

     Subtitle D--Community Living Assistance Services and Supports

     SEC. 2581. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE 
                   PROGRAM FOR PURCHASING COMMUNITY LIVING 
                   ASSISTANCE SERVICES AND SUPPORT (CLASS 
                   PROGRAM).

       (a) Establishment of CLASS Program.--The Public Health 
     Service Act (42 U.S.C. 201 et seq.), as amended by section 
     2301, is amended by adding at the end the following:

    ``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

     ``SEC. 3201. PURPOSE.

       ``The purpose of this title is to establish a national 
     voluntary insurance program for purchasing community living 
     assistance services and supports in order to--
       ``(1) provide individuals with functional limitations with 
     tools that will allow them to maintain their personal and 
     financial independence and live in the community through a 
     new financing strategy for community living assistance 
     services and supports;
       ``(2) establish an infrastructure that will help address 
     the Nation's community living assistance services and 
     supports needs;

[[Page 27384]]

       ``(3) alleviate burdens on family caregivers; and
       ``(4) address institutional bias by providing a financing 
     mechanism that supports personal choice and independence to 
     live in the community.

     ``SEC. 3202. DEFINITIONS.

       ``In this title:
       ``(1) Active enrollee.--The term `active enrollee' means an 
     individual who is enrolled in the CLASS program in accordance 
     with section 3204 and who has paid any premiums due to 
     maintain such enrollment.
       ``(2) Actively employed.--The term `actively employed' 
     means an individual who--
       ``(A) is reporting for work at the individual's usual place 
     of employment or at another location to which the individual 
     is required to travel because of the individual's employment 
     (or in the case of an individual who is a member of the 
     uniformed services, is on active duty and is physically able 
     to perform the duties of the individual's position); and
       ``(B) is able to perform all the usual and customary duties 
     of the individual's employment on the individual's regular 
     work schedule.
       ``(3) Activities of daily living.--The term `activities of 
     daily living' has the meaning given the term in section 
     7702B(c)(2)(B) of the Internal Revenue Code of 1986.
       ``(4) CLASS program.--The term `CLASS program' means the 
     program established under this title.
       ``(5) Eligibility assessment system.--The term `Eligibility 
     Assessment System' means the entity designated by the 
     Secretary under section 3205(a)(2)(A)(i).
       ``(6) Eligible beneficiary.--
       ``(A) In general.--The term `eligible beneficiary' means 
     any individual who is an active enrollee in the CLASS program 
     and, as of the date described in subparagraph (B)--
       ``(i) has paid premiums for enrollment in such program for 
     at least 60 months;
       ``(ii) has earned, for each calendar year that occurs 
     during the first 60 months for which the individual has paid 
     premiums for enrollment in the program, at least an amount 
     equal to the amount of wages and self-employment income which 
     an individual must have in order to be credited with a 
     quarter of coverage under section 213(d) of the Social 
     Security Act for that year; and
       ``(iii) has paid premiums for enrollment in such program 
     for at least 24 consecutive months, if a lapse in premium 
     payments of more than 3 months has occurred during the period 
     that begins on the date of the individual's enrollment and 
     ends on the date of such determination.
       ``(B) Date described.--For purposes of subparagraph (A), 
     the date described in this subparagraph is the date on which 
     the individual is determined to have a functional limitation 
     described in section 3203(a)(1)(C) that is expected to last 
     for a continuous period of more than 90 days.
       ``(C) Regulations.--The Secretary shall promulgate 
     regulations specifying exceptions to the minimum earnings 
     requirements under subparagraph (A)(ii) for purposes of being 
     considered an eligible beneficiary for certain populations.
       ``(7) Hospital; nursing facility; intermediate care 
     facility for the mentally retarded; institution for mental 
     diseases.--The terms `hospital', `nursing facility', 
     `intermediate care facility for the mentally retarded', and 
     `institution for mental diseases' have the meanings given 
     such terms for purposes of Medicaid.
       ``(8) CLASS independence advisory council.--The term `CLASS 
     Independence Advisory Council' or `Council' means the 
     Advisory Council established under section 3207 to advise the 
     Secretary.
       ``(9) CLASS independence benefit plan.--The term `CLASS 
     Independence Benefit Plan' means the benefit plan developed 
     and designated by the Secretary in accordance with section 
     3203.
       ``(10) CLASS independence fund.--The term `CLASS 
     Independence Fund' or `Fund' means the fund established under 
     section 3206.
       ``(11) Medicaid.--The term `Medicaid' means the program 
     established under title XIX of the Social Security Act.
       ``(12) Protection and advocacy system.--The term 
     `Protection and Advocacy System' means the system for each 
     State established under section 143 of the Developmental 
     Disabilities Assistance and Bill of Rights Act of 2000.

     ``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.

       ``(a) Process for Development.--
       ``(1) In general.--The Secretary, in consultation with 
     appropriate actuaries and other experts, shall develop at 
     least 3 actuarially sound benefit plans as alternatives for 
     consideration for designation by the Secretary as the CLASS 
     Independence Benefit Plan under which eligible beneficiaries 
     shall receive benefits under this title. Each of the plan 
     alternatives developed shall be designed to provide eligible 
     beneficiaries with the benefits described in section 3205 
     consistent with the following requirements:
       ``(A) Premiums.--Beginning with the first year of the CLASS 
     program, and for each year thereafter, the Secretary shall 
     establish all premiums to be paid by enrollees for the year 
     based on an actuarial analysis of the 75-year costs of the 
     program that ensures solvency throughout such 75-year period.
       ``(B) Vesting period.--A 5-year vesting period for 
     eligibility for benefits.
       ``(C) Benefit triggers.--A benefit trigger for provision of 
     benefits that requires a determination that an individual has 
     a functional limitation, as certified by a licensed health 
     care practitioner, described in any of the following clauses 
     that is expected to last for a continuous period of more than 
     90 days:
       ``(i) The individual is determined to be unable to perform 
     at least the minimum number (which may be 2 or 3) of 
     activities of daily living as are required under the plan for 
     the provision of benefits without substantial assistance (as 
     defined by the Secretary) from another individual.
       ``(ii) The individual requires substantial supervision to 
     protect the individual from threats to health and safety due 
     to substantial cognitive impairment.
       ``(iii) The individual has a level of functional limitation 
     similar (as determined under regulations prescribed by the 
     Secretary) to the level of functional limitation described in 
     clause (i) or (ii).
       ``(D) Cash benefit.--Payment of a cash benefit that 
     satisfies the following requirements:
       ``(i) Minimum required amount.--The benefit amount provides 
     an eligible beneficiary with not less than an average of $50 
     per day (as determined based on the reasonably expected 
     distribution of beneficiaries receiving benefits at various 
     benefit levels).
       ``(ii) Amount scaled to functional ability.--The benefit 
     amount is varied based on a scale of functional ability, with 
     not less than 2, and not more than 6, benefit level amounts.
       ``(iii) Daily or weekly.--The benefit is paid on a daily or 
     weekly basis.
       ``(iv) No lifetime or aggregate limit.--The benefit is not 
     subject to any lifetime or aggregate limit.
       ``(2) Review and recommendation by the class independence 
     advisory council.--The CLASS Independence Advisory Council 
     shall--
       ``(A) evaluate the alternative benefit plans developed 
     under paragraph (1); and
       ``(B) recommend for designation as the CLASS Independence 
     Benefit Plan for offering to the public the plan that the 
     Council determines best balances price and benefits to meet 
     enrollees' needs in an actuarially sound manner, while 
     optimizing the probability of the long-term sustainability of 
     the CLASS program.
       ``(3) Designation by the secretary.--Not later than October 
     1, 2012, the Secretary, taking into consideration the 
     recommendation of the CLASS Independence Advisory Council 
     under paragraph (2)(B), shall designate a benefit plan as the 
     CLASS Independence Benefit Plan. The Secretary shall publish 
     such designation, along with details of the plan and the 
     reasons for the selection by the Secretary, in a final rule 
     that allows for a period of public comment.
       ``(b) Additional Premium Requirements.--
       ``(1) Adjustment of premiums.--
       ``(A) In general.--Except as provided in subparagraphs (B), 
     (C), (D), and (E), the amount of the monthly premium 
     determined for an individual upon such individual's 
     enrollment in the CLASS program shall remain the same for as 
     long as the individual is an active enrollee in the program.
       ``(B) Recalculated premium if required for program 
     solvency.--
       ``(i) In general.--Subject to clause (ii), if the Secretary 
     determines, based on the most recent report of the Board of 
     Trustees of the CLASS Independence Fund, the advice of the 
     CLASS Independence Advisory Council, and the annual report of 
     the Inspector General of the Department of Health and Human 
     Services, and waste, fraud, and abuse, or such other 
     information as the Secretary determines appropriate, that the 
     monthly premiums and income to the CLASS Independence Fund 
     for a year are projected to be insufficient with respect to 
     the 20-year period that begins with that year, the Secretary 
     shall adjust the monthly premiums for individuals enrolled in 
     the CLASS program as necessary.
       ``(ii) Exemption from increase.--Any increase in a monthly 
     premium imposed as result of a determination described in 
     clause (i) shall not apply with respect to the monthly 
     premium of any active enrollee who--

       ``(I) has attained age 65;
       ``(II) has paid premiums for enrollment in the program for 
     at least 20 years; and
       ``(III) is not actively employed.

       ``(C) Recalculated premium if reenrollment after more than 
     a 3-month lapse.--
       ``(i) In general.--The reenrollment of an individual after 
     a 90-day period during which the individual failed to pay the 
     monthly premium required to maintain the individual's 
     enrollment in the CLASS program shall be treated as an 
     initial enrollment for purposes of age-adjusting the premium 
     for enrollment in the program.
       ``(ii) Credit for prior months if reenrolled within 5 
     years.--An individual who reenrolls in the CLASS program 
     after such a 90-day period and before the end of the 5-year 
     period that begins with the first month for which the 
     individual failed to pay the monthly premium required to 
     maintain

[[Page 27385]]

     the individual's enrollment in the program shall be--

       ``(I) credited with any months of paid premiums that 
     accrued prior to the individual's lapse in enrollment; and
       ``(II) notwithstanding the total amount of any such 
     credited months, required to satisfy section 3202(6)(A)(ii) 
     before being eligible to receive benefits.

       ``(D) Penalty for reenrollment after 5-year lapse.--In the 
     case of an individual who reenrolls in the CLASS program 
     after the end of the 5-year period described in subparagraph 
     (C)(ii), the monthly premium required for the individual 
     shall be the age-adjusted premium that would be applicable to 
     an initially enrolling individual who is the same age as the 
     reenrolling individual, increased by the greater of--
       ``(i) an amount that the Secretary determines is 
     actuarially sound for each month that occurs during the 
     period that begins with the first month for which the 
     individual failed to pay the monthly premium required to 
     maintain the individual's enrollment in the CLASS program and 
     ends with the month preceding the month in which the 
     reenrollment is effective; or
       ``(ii) 1 percent of the applicable age-adjusted premium for 
     each such month occurring in such period.
       ``(2) Administrative expenses.--In determining the monthly 
     premiums for the CLASS program, the Secretary may factor in 
     costs for administering the program, not to exceed--
       ``(A) in the case of the first 5 years in which the program 
     is in effect under this title, an amount equal to 3 percent 
     of all premiums paid during each such year; and
       ``(B) in the case of subsequent years, an amount equal to 5 
     percent of the total amount of all expenditures (including 
     benefits paid) under this title with respect to that year.
       ``(3) No underwriting requirements.--No underwriting (other 
     than on the basis of age in accordance with paragraph (2)) 
     shall be used to--
       ``(A) determine the monthly premium for enrollment in the 
     CLASS program; or
       ``(B) prevent an individual from enrolling in the program.

     ``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.

       ``(a) Automatic Enrollment.--
       ``(1) In general.--Subject to paragraph (2), the Secretary 
     shall establish procedures under which each individual 
     described in subsection (c) shall be automatically enrolled 
     in the CLASS program by an employer of such individual under 
     rules similar to the rules of sections 401(k)(13) and 414(w) 
     of the Internal Revenue Code of 1986.
       ``(2) Alternative enrollment procedures.--The procedures 
     established under paragraph (1) shall provide for an 
     alternative enrollment process for an individual described in 
     subsection (c) in the case of such an individual--
       ``(A) who is self-employed;
       ``(B) who has more than 1 employer;
       ``(C) whose employer does not elect to participate in the 
     automatic enrollment process established by the Secretary; or
       ``(D) who is a spouse described in subsection (c)(2) of who 
     is not subject to automatic enrollment.
       ``(3) Administration.--
       ``(A) In general.--The Secretary shall, by regulation, 
     establish procedures to--
       ``(i) ensure that an individual is not automatically 
     enrolled in the CLASS program by more than 1 employer; and
       ``(ii) allow for an individual's employer to deduct a 
     premium for a spouse described in subsection (c)(1)(B) who is 
     not subject to automatic enrollment.
       ``(B) Form.--Enrollment in the CLASS program shall be made 
     in such manner as the Secretary may prescribe in order to 
     ensure ease of administration.
       ``(b) Election To Opt-Out.--An individual described in 
     subsection (c) may elect to waive enrollment in the CLASS 
     program at any time in such form and manner as the Secretary 
     shall prescribe.
       ``(c) Individual Described.--For purposes of enrolling in 
     the CLASS program, an individual described in this paragraph 
     is--
       ``(1) an individual--
       ``(A) who has attained age 18;
       ``(B) who receives wages on which there is imposed a tax 
     under section 3101(a) or 3201(a) of the Internal Revenue Code 
     of 1986;
       ``(C) who is actively employed; and
       ``(D) who is not--
       ``(i) a patient in a hospital or nursing facility, an 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases and receiving medical 
     assistance under Medicaid; or
       ``(ii) confined in a jail, prison, other penal institution 
     or correctional facility, or by court order pursuant to 
     conviction of a criminal offense or in connection with a 
     verdict or finding described in section 202(x)(1)(A)(ii) of 
     the Social Security Act; or
       ``(2) the spouse of an individual described in paragraph 
     (1) and who would be an individual so described but for 
     subparagraph (B) or (C) of that paragraph.
       ``(d) Rule of Construction.--Nothing in this title shall be 
     construed as requiring an active enrollee to continue to 
     satisfy subparagraph (B) or (C) of subsection (c)(1) in order 
     to maintain enrollment in the CLASS program.
       ``(e) Payment.--
       ``(1) Payroll deduction.--An amount equal to the monthly 
     premium for the enrollment in the CLASS program of an 
     individual shall be deducted from the wages of such 
     individual in accordance with such procedures as the 
     Secretary shall establish for employers who elect to deduct 
     and withhold such premiums on behalf of enrolled employees.
       ``(2) Alternative payment mechanism.--The Secretary shall 
     establish alternative procedures for the payment of monthly 
     premiums by an individual enrolled in the CLASS program who 
     does not have an employer who elects to deduct and withhold 
     premiums in accordance with subparagraph (A).
       ``(f) Transfer of Premiums Collected.--
       ``(1) In general.--During each calendar year the Secretary 
     of the Treasury shall deposit into the CLASS Independence 
     Fund a total amount equal, in the aggregate, to 100 percent 
     of the premiums collected during that year.
       ``(2) Transfers based on estimates.--The amount deposited 
     pursuant to paragraph (1) shall be transferred in at least 
     monthly payments to the CLASS Independence Fund on the basis 
     of estimates by the Secretary and certified to the Secretary 
     of the Treasury of the amounts collected in accordance with 
     this section. Proper adjustments shall be made in amounts 
     subsequently transferred to the Fund to the extent prior 
     estimates were in excess of, or were less than, actual 
     amounts collected.
       ``(g) Other Enrollment and Disenrollment Opportunities.--
     The Secretary shall establish procedures under which--
       ``(1) an individual who, in the year of the individual's 
     initial eligibility to enroll in the CLASS program, has 
     elected to waive enrollment in the program, is eligible to 
     elect to enroll in the program, in such form and manner as 
     the Secretary shall establish, only during an open enrollment 
     period established by the Secretary that is specific to the 
     individual and that may not occur more frequently than 
     biennially after the date on which the individual first 
     elected to waive enrollment in the program; and
       ``(2) an individual shall only be permitted to disenroll 
     from the program during an annual disenrollment period 
     established by the Secretary and in such form and manner as 
     the Secretary shall establish.

     ``SEC. 3205. BENEFITS.

       ``(a) Determination of Eligibility.--
       ``(1) Application for receipt of benefits.--The Secretary 
     shall establish procedures under which an active enrollee 
     shall apply for receipt of benefits under the CLASS 
     Independence Benefit Plan.
       ``(2) Eligibility assessments.--
       ``(A) In general.--Not later than January 1, 2012, the 
     Secretary shall--
       ``(i) designate an entity (other than a service with which 
     the Commissioner of Social Security has entered into an 
     agreement, with respect to any State, to make disability 
     determinations for purposes of title II or XVI of the Social 
     Security Act) to serve as an Eligibility Assessment System by 
     providing for eligibility assessments of active enrollees who 
     apply for receipt of benefits;
       ``(ii) enter into an agreement with the Protection and 
     Advocacy System for each State to provide advocacy services 
     in accordance with subsection (d); and
       ``(iii) enter into an agreement with public and private 
     entities to provide advice and assistance counseling in 
     accordance with subsection (e).
       ``(B) Regulations.--The Secretary shall promulgate 
     regulations to develop an expedited nationally equitable 
     eligibility determination process, as certified by a licensed 
     health care practitioner, an appeals process, and a 
     redetermination process, as certified by a licensed health 
     care practitioner, including whether an applicant is eligible 
     for a cash benefit under the program and if so, the amount of 
     the cash benefit (in accordance the sliding scale established 
     under the plan).
       ``(C) Presumptive eligibility for certain institutionalized 
     enrollees planning to discharge.--An active enrollee shall be 
     deemed presumptively eligible if the enrollee--
       ``(i) has applied for, and attests is eligible for, the 
     maximum cash benefit available under the sliding scale 
     established under the CLASS Independence Benefit Plan;
       ``(ii) is a patient in a hospital (but only if the 
     hospitalization is for long-term care), nursing facility, 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases; and
       ``(iii) is in the process of, or about to being the process 
     of, planning to discharge from the hospital, facility, or 
     institution, or within 60 days from the date of discharge 
     from the hospital, facility, or institution.
       ``(D) Appeals.--The Secretary shall establish procedures 
     under which an applicant for benefits under the CLASS 
     Independence Benefit Plan shall be guaranteed the right to 
     appeal an adverse determination.
       ``(b) Benefits.--An eligible beneficiary shall receive the 
     following benefits under the CLASS Independence Benefit Plan:
       ``(1) Cash benefit.--A cash benefit established by the 
     Secretary in accordance with

[[Page 27386]]

     the requirements of section 3203(a)(1)(D) that--
       ``(A) the first year in which beneficiaries receive the 
     benefits under the plan, is not less than the average dollar 
     amount specified in clause (i) of such section; and
       ``(B) for any subsequent year, is not less than the average 
     per day dollar limit applicable under this subparagraph for 
     the preceding year, increased by the percentage increase in 
     the consumer price index for all urban consumers (U.S. city 
     average) over the previous year.
       ``(2) Advocacy services.--Advocacy services in accordance 
     with subsection (d).
       ``(3) Advice and assistance counseling.--Advice and 
     assistance counseling in accordance with subsection (e).
       ``(4) Administrative expenses.--Advocacy services and 
     advise and assistance counseling services under paragraphs 
     (2) and (3) of this subsection shall be included as 
     administrative expenses under section 3203(b)(2).
       ``(c) Payment of Benefits.--
       ``(1) Life independence account.--
       ``(A) In general.--The Secretary shall establish procedures 
     for administering the provision of benefits to eligible 
     beneficiaries under the CLASS Independence Benefit Plan, 
     including the payment of the cash benefit for the beneficiary 
     into a Life Independence Account established by the Secretary 
     on behalf of each eligible beneficiary.
       ``(B) Use of cash benefits.--Cash benefits paid into a Life 
     Independence Account of an eligible beneficiary shall be used 
     to purchase nonmedical services and supports that the 
     beneficiary needs to maintain his or her independence at home 
     or in another residential setting of their choice in the 
     community, including (but not limited to) home modifications, 
     assistive technology, accessible transportation, homemaker 
     services, respite care, personal assistance services, home 
     care aides, and nursing support. Nothing in the preceding 
     sentence shall prevent an eligible beneficiary from using 
     cash benefits paid into a Life Independence Account for 
     obtaining assistance with decisionmaking concerning medical 
     care, including the right to accept or refuse medical or 
     surgical treatment and the right to formulate advance 
     directives or other written instructions recognized under 
     State law, such as a living will or durable power of attorney 
     for health care, in the case that an injury or illness causes 
     the individual to be unable to make health care decisions.
       ``(C) Electronic management of funds.--The Secretary shall 
     establish procedures for--
       ``(i) crediting an account established on behalf of a 
     beneficiary with the beneficiary's cash daily benefit;
       ``(ii) allowing the beneficiary to access such account 
     through debit cards; and
       ``(iii) accounting for withdrawals by the beneficiary from 
     such account.
       ``(D) Primary payor rules for beneficiaries who are 
     enrolled in medicaid.--In the case of an eligible beneficiary 
     who is enrolled in Medicaid, the following payment rules 
     shall apply:
       ``(i) Institutionalized beneficiary.--If the beneficiary is 
     a patient in a hospital, nursing facility, intermediate care 
     facility for the mentally retarded, or an institution for 
     mental diseases, the beneficiary shall retain an amount equal 
     to 5 percent of the beneficiary's daily or weekly cash 
     benefit (as applicable) (which shall be in addition to the 
     amount of the beneficiary's personal needs allowance provided 
     under Medicaid), and the remainder of such benefit shall be 
     applied toward the facility's cost of providing the 
     beneficiary's care, and Medicaid shall provide secondary 
     coverage for such care.
       ``(ii) Beneficiaries receiving home and community-based 
     services.--

       ``(I) 50 percent of benefit retained by beneficiary.--
     Subject to subclause (II), if a beneficiary is receiving 
     medical assistance under Medicaid for home and community-
     based services, the beneficiary shall retain an amount equal 
     to 50 percent of the beneficiary's daily or weekly cash 
     benefit (as applicable), and the remainder of the daily or 
     weekly cash benefit shall be applied toward the cost to the 
     State of providing such assistance (and shall not be used to 
     claim Federal matching funds under Medicaid), and Medicaid 
     shall provide secondary coverage for the remainder of any 
     costs incurred in providing such assistance.
       ``(II) Requirement for state offset.--A State shall be paid 
     the remainder of a beneficiary's daily or weekly cash benefit 
     under subclause (I) only if the State home and community-
     based waiver under section 1115 of the Social Security Act or 
     subsection (c) or (d) of section 1915 of such Act, or the 
     State plan amendment under subsection (i) of such section 
     does not include a waiver of the requirements of section 
     1902(a)(1) of the Social Security Act (relating to 
     statewideness) or of section 1902(a)(10)(B) of such Act 
     (relating to comparability) and the State offers at a minimum 
     case management services, personal care services, 
     habilitation services, and respite care under such a waiver 
     or State plan amendment.
       ``(III) Definition of home and community-based services.--
     In this clause, the term `home and community-based services' 
     means any services which may be offered under a home and 
     community-based waiver authorized for a State under section 
     1115 of the Social Security Act or subsection (c) or (d) of 
     section 1915 of such Act or under a State plan amendment 
     under subsection (i) of such section.

       ``(iii) Beneficiaries enrolled in programs of all-inclusive 
     care for the elderly (pace).--

       ``(I) In general.--Subject to subclause (II), if a 
     beneficiary is receiving medical assistance under Medicaid 
     for PACE program services under section 1934 of the Social 
     Security Act, the beneficiary shall retain an amount equal to 
     50 percent of the beneficiary's daily or weekly cash benefit 
     (as applicable), and the remainder of the daily or weekly 
     cash benefit shall be applied toward the cost to the State of 
     providing such assistance (and shall not be used to claim 
     Federal matching funds under Medicaid), and Medicaid shall 
     provide secondary coverage for the remainder of any costs 
     incurred in providing such assistance.
       ``(II) Institutionalized recipients of pace program 
     services.--If a beneficiary receiving assistance under 
     Medicaid for PACE program services is a patient in a 
     hospital, nursing facility, intermediate care facility for 
     the mentally retarded, or an institution for mental diseases, 
     the beneficiary shall be treated as in institutionalized 
     beneficiary under clause (i).

       ``(2) Authorized representatives.--
       ``(A) In general.--The Secretary shall establish procedures 
     to allow access to a beneficiary's cash benefits by an 
     authorized representative of the eligible beneficiary on 
     whose behalf such benefits are paid.
       ``(B) Quality assurance and protection against fraud and 
     abuse.--The procedures established under subparagraph (A) 
     shall ensure that authorized representatives of eligible 
     beneficiaries comply with standards of conduct established by 
     the Secretary, including standards requiring that such 
     representatives provide quality services on behalf of such 
     beneficiaries, do not have conflicts of interest, and do not 
     misuse benefits paid on behalf of such beneficiaries or 
     otherwise engage in fraud or abuse.
       ``(3) Commencement of benefits.--Benefits shall be paid to, 
     or on behalf of, an eligible beneficiary beginning with the 
     first month in which an application for such benefits is 
     approved.
       ``(4) Rollover option for lump-sum payment.--An eligible 
     beneficiary may elect to--
       ``(A) defer payment of their daily or weekly benefit and to 
     rollover any such deferred benefits from month-to-month, but 
     not from year-to-year; and
       ``(B) receive a lump-sum payment of such deferred benefits 
     in an amount that may not exceed the lesser of--
       ``(i) the total amount of the accrued deferred benefits; or
       ``(ii) the applicable annual benefit.
       ``(5) Period for determination of annual benefits.--
       ``(A) In general.--The applicable period for determining 
     with respect to an eligible beneficiary the applicable annual 
     benefit and the amount of any accrued deferred benefits is 
     the 12-month period that commences with the first month in 
     which the beneficiary began to receive such benefits, and 
     each 12-month period thereafter.
       ``(B) Inclusion of increased benefits.--The Secretary shall 
     establish procedures under which cash benefits paid to an 
     eligible beneficiary that increase or decrease as a result of 
     a change in the functional status of the beneficiary before 
     the end of a 12-month benefit period shall be included in the 
     determination of the applicable annual benefit paid to the 
     eligible beneficiary.
       ``(C) Recoupment of unpaid, accrued benefits.--
       ``(i) In general.--The Secretary, in coordination with the 
     Secretary of the Treasury, shall recoup any accrued benefits 
     in the event of--

       ``(I) the death of a beneficiary; or
       ``(II) the failure of a beneficiary to elect under 
     paragraph (4)(B) to receive such benefits as a lump-sum 
     payment before the end of the 12-month period in which such 
     benefits accrued.

       ``(ii) Payment into class independence fund.--Any benefits 
     recouped in accordance with clause (i) shall be paid into the 
     CLASS Independence Fund and used in accordance with section 
     3206.
       ``(6) Requirement to recertify eligibility for receipt of 
     benefits.--An eligible beneficiary shall periodically, as 
     determined by the Secretary--
       ``(A) recertify by submission of medical evidence the 
     beneficiary's continued eligibility for receipt of benefits; 
     and
       ``(B) submit records of expenditures attributable to the 
     aggregate cash benefit received by the beneficiary during the 
     preceding year.
       ``(7) Supplement, not supplant other health care 
     benefits.--Subject to the Medicaid payment rules under 
     paragraph (1)(D), benefits received by an eligible 
     beneficiary shall supplement, but not supplant, other health 
     care benefits for which the beneficiary is eligible under 
     Medicaid or any other Federally funded program that provides 
     health care benefits or assistance.
       ``(d) Advocacy Services.--An agreement entered into under 
     subsection (a)(2)(A)(ii) shall require the Protection and 
     Advocacy System for the State to--

[[Page 27387]]

       ``(1) assign, as needed, an advocacy counselor to each 
     eligible beneficiary that is covered by such agreement and 
     who shall provide an eligible beneficiary with--
       ``(A) information regarding how to access the appeals 
     process established for the program;
       ``(B) assistance with respect to the annual recertification 
     and notification required under subsection (c)(6); and
       ``(C) such other assistance with obtaining services as the 
     Secretary, by regulation, shall require; and
       ``(2) ensure that the System and such counselors comply 
     with the requirements of subsection (h).
       ``(e) Advice and Assistance Counseling.--An agreement 
     entered into under subsection (a)(2)(A)(iii) shall require 
     the entity to assign, as requested by an eligible beneficiary 
     that is covered by such agreement, an advice and assistance 
     counselor who shall provide an eligible beneficiary with 
     information regarding--
       ``(1) accessing and coordinating long-term services and 
     supports in the most integrated setting;
       ``(2) possible eligibility for other benefits and services;
       ``(3) development of a service and support plan;
       ``(4) information about programs established under the 
     Assistive Technology Act of 1998 and the services offered 
     under such programs;
       ``(5) available assistance with decisionmaking concerning 
     medical care, including the right to accept or refuse medical 
     or surgical treatment and the right to formulate advance 
     directives or other written instructions recognized under 
     State law, such as a living will or durable power of attorney 
     for health care, in the case that an injury or illness causes 
     the individual to be unable to make health care decisions; 
     and
       ``(6) such other services as the Secretary, by regulation, 
     may require.
       ``(f) No Effect on Eligibility for Other Benefits.--
     Benefits paid to an eligible beneficiary under the CLASS 
     program shall be disregarded for purposes of determining or 
     continuing the beneficiary's eligibility for receipt of 
     benefits under any other Federal, State, or locally funded 
     assistance program, including benefits paid under titles II, 
     XVI, XVIII, XIX, or XXI of the Social Security Act, under the 
     laws administered by the Secretary of Veterans Affairs, under 
     low-income housing assistance programs, or under the 
     supplemental nutrition assistance program established under 
     the Food and Nutrition Act of 2008.
       ``(g) Rule of Construction.--Nothing in this title shall be 
     construed as prohibiting benefits paid under the CLASS 
     Independence Benefit Plan from being used to compensate a 
     family caregiver for providing community living assistance 
     services and supports to an eligible beneficiary.
       ``(h) Protection Against Conflicts of Interest.--The 
     Secretary shall establish procedures to ensure that the 
     Eligibility Assessment System, the Protection and Advocacy 
     System for a State, advocacy counselors for eligible 
     beneficiaries, and any other entities that provide services 
     to active enrollees and eligible beneficiaries under the 
     CLASS program comply with the following:
       ``(1) If the entity provides counseling or planning 
     services, such services are provided in a manner that fosters 
     the best interests of the active enrollee or beneficiary.
       ``(2) The entity has established operating procedures that 
     are designed to avoid or minimize conflicts of interest 
     between the entity and an active enrollee or beneficiary.
       ``(3) The entity provides information about all services 
     and options available to the active enrollee or beneficiary, 
     to the best of its knowledge, including services available 
     through other entities or providers.
       ``(4) The entity assists the active enrollee or beneficiary 
     to access desired services, regardless of the provider.
       ``(5) The entity reports the number of active enrollees and 
     beneficiaries provided with assistance by age, disability, 
     and whether such enrollees and beneficiaries received 
     services from the entity or another entity.
       ``(6) If the entity provides counseling or planning 
     services, the entity ensures that an active enrollee or 
     beneficiary is informed of any financial interest that the 
     entity has in a service provider.
       ``(7) The entity provides an active enrollee or beneficiary 
     with a list of available service providers that can meet the 
     needs of the active enrollee or beneficiary.

     ``SEC. 3206. CLASS INDEPENDENCE FUND.

       ``(a) Establishment of CLASS Independence Fund.--There is 
     established in the Treasury of the United States a trust fund 
     to be known as the `CLASS Independence Fund'. The Secretary 
     of the Treasury shall serve as Managing Trustee of such Fund. 
     The Fund shall consist of all amounts derived from payments 
     into the Fund under sections 3204(f) and 3205(c)(5)(C)(ii), 
     and remaining after investment of such amounts under 
     subsection (b), including additional amounts derived as 
     income from such investments. The amounts held in the Fund 
     are appropriated and shall remain available without fiscal 
     year limitation--
       ``(1) to be held for investment on behalf of individuals 
     enrolled in the CLASS program;
       ``(2) to pay the administrative expenses related to the 
     Fund and to investment under subsection (b); and
       ``(3) to pay cash benefits to eligible beneficiaries under 
     the CLASS Independence Benefit Plan.
       ``(b) Investment of Fund Balance.--The Secretary of the 
     Treasury shall invest and manage the CLASS Independence Fund 
     in the same manner, and to the same extent, as the Federal 
     Supplementary Medical Insurance Trust Fund may be invested 
     and managed under subsections (c), (d), and (e) of section 
     1841(d) of the Social Security Act.
       ``(c) Board of Trustees.--
       ``(1) In general.--With respect to the CLASS Independence 
     Fund, there is hereby created a body to be known as the Board 
     of Trustees of the CLASS Independence Fund (hereinafter in 
     this section referred to as the `Board of Trustees') composed 
     of the Secretary of the Treasury, the Secretary of Labor, and 
     the Secretary of Health and Human Services, all ex officio, 
     and of two members of the public (both of whom may not be 
     from the same political party), who shall be nominated by the 
     President for a term of 4 years and subject to confirmation 
     by the Senate. A member of the Board of Trustees serving as a 
     member of the public and nominated and confirmed to fill a 
     vacancy occurring during a term shall be nominated and 
     confirmed only for the remainder of such term. An individual 
     nominated and confirmed as a member of the public may serve 
     in such position after the expiration of such member's term 
     until the earlier of the time at which the member's successor 
     takes office or the time at which a report of the Board is 
     first issued under paragraph (2) after the expiration of the 
     member's term. The Secretary of the Treasury shall be the 
     Managing Trustee of the Board of Trustees. The Board of 
     Trustees shall meet not less frequently than once each 
     calendar year. A person serving on the Board of Trustees 
     shall not be considered to be a fiduciary and shall not be 
     personally liable for actions taken in such capacity with 
     respect to the Trust Fund.
       ``(2) Duties.--
       ``(A) In general.--It shall be the duty of the Board of 
     Trustees to do the following:
       ``(i) Hold the CLASS Independence Fund.
       ``(ii) Report to the Congress not later than the first day 
     of April of each year on the operation and status of the 
     CLASS Independence Fund during the preceding fiscal year and 
     on its expected operation and status during the current 
     fiscal year and the next 2 fiscal years.
       ``(iii) Report immediately to the Congress whenever the 
     Board is of the opinion that the amount of the CLASS 
     Independence Fund is not actuarially sound in regards to the 
     projections under section 3203(b)(1)(B)(i).
       ``(iv) Review the general policies followed in managing the 
     CLASS Independence Fund, and recommend changes in such 
     policies, including necessary changes in the provisions of 
     law which govern the way in which the CLASS Independence Fund 
     is to be managed.
       ``(B) Report.--The report provided for in subparagraph 
     (A)(ii) shall--
       ``(i) include--

       ``(I) a statement of the assets of, and the disbursements 
     made from, the CLASS Independence Fund during the preceding 
     fiscal year;
       ``(II) an estimate of the expected income to, and 
     disbursements to be made from, the CLASS Independence Fund 
     during the current fiscal year and each of the next 2 fiscal 
     years;
       ``(III) a statement of the actuarial status of the CLASS 
     Independence Fund for the current fiscal year, each of the 
     next 2 fiscal years, and as projected over the 75-year period 
     beginning with the current fiscal year; and
       ``(IV) an actuarial opinion certifying that the techniques 
     and methodologies used are generally accepted within the 
     actuarial profession and that the assumptions and cost 
     estimates used are reasonable; and

       ``(ii) be printed as a House document of the session of the 
     Congress to which the report is made.
       ``(C) Recommendations.--If the Board of Trustees determines 
     that enrollment trends and expected future benefit claims on 
     the CLASS Independence Fund are not actuarially sound in 
     regards to the projections under section 3203(b)(1)(B)(i) and 
     are unlikely to be resolved with reasonable premium increases 
     or through other means, the Board of Trustees shall include 
     in the report provided for in subparagraph (A)(ii) 
     recommendations for such legislative action as the Board of 
     Trustees determine to be appropriate, including whether to 
     adjust monthly premiums or impose a temporary moratorium on 
     new enrollments.

     ``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.

       ``(a) Establishment.--There is hereby created an Advisory 
     Committee to be known as the `CLASS Independence Advisory 
     Council'.
       ``(b) Membership.--
       ``(1) In general.--The CLASS Independence Advisory Council 
     shall be composed of not more than 15 individuals, not 
     otherwise in the employ of the United States--
       ``(A) who shall be appointed by the President without 
     regard to the civil service laws and regulations; and

[[Page 27388]]

       ``(B) a majority of whom shall be representatives of 
     individuals who participate or are likely to participate in 
     the CLASS program, and shall include representatives of older 
     and younger workers, individuals with disabilities, family 
     caregivers of individuals who require services and supports 
     to maintain their independence at home or in another 
     residential setting of their choice in the community, 
     individuals with expertise in long-term care or disability 
     insurance, actuarial science, economics, and other relevant 
     disciplines, as determined by the Secretary.
       ``(2) Terms.--
       ``(A) In general.--The members of the CLASS Independence 
     Advisory Council shall serve overlapping terms of 3 years 
     (unless appointed to fill a vacancy occurring prior to the 
     expiration of a term, in which case the individual shall 
     serve for the remainder of the term).
       ``(B) Limitation.--A member shall not be eligible to serve 
     for more than 2 consecutive terms.
       ``(3) Chair.--The President shall, from time to time, 
     appoint one of the members of the CLASS Independence Advisory 
     Council to serve as the Chair.
       ``(c) Duties.--The CLASS Independence Advisory Council 
     shall advise the Secretary on matters of general policy in 
     the administration of the CLASS program established under 
     this title and in the formulation of regulations under this 
     title including with respect to--
       ``(1) the development of the CLASS Independence Benefit 
     Plan under section 3203; and
       ``(2) the determination of monthly premiums under such 
     plan.
       ``(d) Application of FACA.--The Federal Advisory Committee 
     Act, other than section 14 of that Act, shall apply to the 
     CLASS Independence Advisory Council.
       ``(e) Authorization of Appropriations.--
       ``(1) In general.--There are authorized to be appropriated 
     to the CLASS Independence Advisory Council to carry out its 
     duties under this section, such sums as may be necessary for 
     fiscal year 2011 and for each fiscal year thereafter.
       ``(2) Availability.--Any sums appropriated under the 
     authorization contained in this section shall remain 
     available, without fiscal year limitation, until expended.

     ``SEC. 3208. REGULATIONS; ANNUAL REPORT.

       ``(a) Regulations.--The Secretary shall promulgate such 
     regulations as are necessary to carry out the CLASS program 
     in accordance with this title. Such regulations shall include 
     provisions to prevent fraud and abuse under the program.
       ``(b) Annual Report.--Beginning January 1, 2014, the 
     Secretary shall submit an annual report to Congress on the 
     CLASS program. Each report shall include the following:
       ``(1) The total number of enrollees in the program.
       ``(2) The total number of eligible beneficiaries during the 
     fiscal year.
       ``(3) The total amount of cash benefits provided during the 
     fiscal year.
       ``(4) A description of instances of fraud or abuse 
     identified during the fiscal year.
       ``(5) Recommendations for such administrative or 
     legislative action as the Secretary determines is necessary 
     to improve the program or to prevent the occurrence of fraud 
     or abuse.

     ``SEC. 3209. INSPECTOR GENERAL'S REPORT.

       ``The Inspector General of the Department of Health and 
     Human Services shall submit an annual report to the Secretary 
     and Congress relating to the overall progress of the CLASS 
     program and of the existence of waste, fraud, and abuse in 
     the CLASS program. Each such report shall include findings in 
     the following areas:
       ``(1) The eligibility determination process.
       ``(2) The provision of cash benefits.
       ``(3) Quality assurance and protection against waste, 
     fraud, and abuse.
       ``(4) Recouping of unpaid and accrued benefits.''.
       (b) Conforming Amendments to Medicaid.--For conforming 
     provisions amending the Medicaid program, see section 1739.

                       Subtitle E--Miscellaneous

     SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EMPLOYMENT 
                   OBLIGATIONS.

       A State is eligible for Federal funds under the provisions 
     of the Public Health Service Act (42 U.S.C. 201 et seq.) only 
     if the State--
       (1) agrees to be subject in its capacity as an employer to 
     each obligation under division A of this Act and the 
     amendments made by such division applicable to persons in 
     their capacity as an employer; and
       (2) assures that all political subdivisions in the State 
     will do the same.

     SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH SERVICE ACT; 
                   LIABILITY PROTECTIONS FOR VOLUNTEER 
                   PRACTITIONERS.

       (a) In General.--Section 224 (42 U.S.C. 233) is amended--
       (1) in subsection (g)(1)(A)--
       (A) in the first sentence, by striking ``or employee'' and 
     inserting ``employee, or (subject to subsection (k)(4)) 
     volunteer practitioner''; and
       (B) in the second sentence, by inserting ``and subsection 
     (k)(4)'' after ``subject to paragraph (5)''; and
       (2) in each of subsections (g), (i), (j), (l), and (m), by 
     striking the term ``employee, or contractor'' each place such 
     term appears and inserting ``employee, volunteer 
     practitioner, or contractor'';
       (3) in subsection (g)(1)(H), by striking the term 
     ``employee, and contractor'' each place such term appears and 
     inserting ``employee, volunteer practitioner, and 
     contractor'';
       (4) in subsection (l), by striking the term ``employee, or 
     any contractor'' and inserting ``employee, volunteer 
     practitioner, or contractor''; and
       (5) in subsections (h)(3) and (k), by striking the term 
     ``employees, or contractors'' each place such term appears 
     and inserting ``employees, volunteer practitioners, or 
     contractors''.
       (b) Applicability; Definition.--Section 224(k) (42 U.S.C. 
     233(k)) is amended by adding at the end the following 
     paragraph:
       ``(4)(A) Subsections (g) through (m) apply with respect to 
     volunteer practitioners beginning with the first fiscal year 
     for which an appropriations Act provides that amounts in the 
     fund under paragraph (2) are available with respect to such 
     practitioners.
       ``(B) For purposes of subsections (g) through (m), the term 
     `volunteer practitioner' means a practitioner who, with 
     respect to an entity described in subsection (g)(4), meets 
     the following conditions:
       ``(i) The practitioner is a licensed physician, a licensed 
     clinical psychologist, or other licensed or certified health 
     care practitioner.
       ``(ii) At the request of such entity, the practitioner 
     provides services to patients of the entity, at a site at 
     which the entity operates or at a site designated by the 
     entity. The weekly number of hours of services provided to 
     the patients by the practitioner is not a factor with respect 
     to meeting conditions under this subparagraph.
       ``(iii) The practitioner does not for the provision of such 
     services receive any compensation from such patients, from 
     the entity, or from third-party payors (including 
     reimbursement under any insurance policy or health plan, or 
     under any Federal or State health benefits program).''.

     SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE OF 
                   PARASITIC DISEASES THAT HAVE BEEN OVERLOOKED 
                   AMONG THE POOREST AMERICANS.

       Not later than 12 months after the date of the enactment of 
     this Act, the Secretary of Health and Human Services shall 
     report to Congress on the epidemiology of, impact of, and 
     appropriate funding required to address neglected diseases of 
     poverty, including neglected parasitic diseases identified as 
     Chagas disease, cysticercosis, toxocariasis, toxoplasmosis, 
     trichomoniasis, the soil-transmitted helminths, and others. 
     The report should provide the information necessary to 
     enhance health policy to accurately evaluate and address the 
     threat of these diseases.

     SEC. 2588. OFFICE OF WOMEN'S HEALTH.

       (a) Health and Human Services Office on Women's Health.--
       (1) Establishment.--Part A of title II (42 U.S.C. 202 et 
     seq.) is amended by adding at the end the following:

     ``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S 
                   HEALTH.

       ``(a) Establishment of Office.--There is established within 
     the Office of the Secretary, an Office on Women's Health 
     (referred to in this section as the `Office'). The Office 
     shall be headed by a Deputy Assistant Secretary for Women's 
     Health who may report to the Secretary.
       ``(b) Duties.--The Secretary, acting through the Office, 
     with respect to the health concerns of women, shall--
       ``(1) establish short-range and long-range goals and 
     objectives within the Department of Health and Human Services 
     and, as relevant and appropriate, coordinate with other 
     appropriate offices on activities within the Department that 
     relate to disease prevention, health promotion, service 
     delivery, research, and public and health care professional 
     education, for issues of particular concern to women 
     throughout their lifespan;
       ``(2) provide expert advice and consultation to the 
     Secretary concerning scientific, legal, ethical, and policy 
     issues relating to women's health;
       ``(3) monitor the Department of Health and Human Services' 
     offices, agencies, and regional activities regarding women's 
     health and identify needs regarding the coordination of 
     activities, including intramural and extramural 
     multidisciplinary activities;
       ``(4) establish a Department of Health and Human Services 
     Coordinating Committee on Women's Health, which shall be 
     chaired by the Deputy Assistant Secretary for Women's Health 
     and composed of senior level representatives from each of the 
     agencies and offices of the Department of Health and Human 
     Services;
       ``(5) establish a National Women's Health Information 
     Center to--
       ``(A) facilitate the exchange of information regarding 
     matters relating to health information, health promotion, 
     preventive health services, research advances, and education 
     in the appropriate use of health care;
       ``(B) facilitate access to such information;
       ``(C) assist in the analysis of issues and problems 
     relating to the matters described in this paragraph; and

[[Page 27389]]

       ``(D) provide technical assistance with respect to the 
     exchange of information (including facilitating the 
     development of materials for such technical assistance);
       ``(6) coordinate efforts to promote women's health programs 
     and policies with the private sector; and
       ``(7) through publications and any other means appropriate, 
     provide for the exchange of information between the Office 
     and recipients of grants, contracts, and agreements under 
     subsection (c), and between the Office and health 
     professionals and the general public.
       ``(c) Grants and Contracts Regarding Duties.--
       ``(1) Authority.--In carrying out subsection (b), the 
     Secretary may make grants to, and enter into cooperative 
     agreements, contracts, and interagency agreements with, 
     public and private entities, agencies, and organizations.
       ``(2) Evaluation and dissemination.--The Secretary shall 
     directly or through contracts with public and private 
     entities, agencies, and organizations, provide for 
     evaluations of projects carried out with financial assistance 
     provided under paragraph (1) and for the dissemination of 
     information developed as a result of such projects.
       ``(d) Reports.--Not later than 1 year after the date of 
     enactment of this section, and every second year thereafter, 
     the Secretary shall prepare and submit to the appropriate 
     committees of Congress a report describing the activities 
     carried out under this section during the period for which 
     the report is being prepared.''
       ``(e) References.--Except as otherwise specified, any 
     reference in Federal law to an Office on Women's Health (in 
     the Department of Health and Human Services) is deemed to be 
     a reference to the Office on Women's Health in the Office of 
     the Secretary.''.
       (2) Transfer of functions.--There are transferred to the 
     Office on Women's Health (established under section 229 of 
     the Public Health Service Act, as added by this section), all 
     functions exercised by the Office on Women's Health of the 
     Public Health Service prior to the date of enactment of this 
     section, including all personnel and compensation authority, 
     all delegation and assignment authority, and all remaining 
     appropriations. All orders, determinations, rules, 
     regulations, permits, agreements, grants, contracts, 
     certificates, licenses, registrations, privileges, and other 
     administrative actions that--
       (A) have been issued, made, granted, or allowed to become 
     effective by the President, any Federal agency or official 
     thereof, or by a court of competent jurisdiction, in the 
     performance of functions transferred under this paragraph; 
     and
       (B) are in effect at the time this section takes effect, or 
     were final before the date of enactment of this section and 
     are to become effective on or after such date;
     shall continue in effect according to their terms until 
     modified, terminated, superseded, set aside, or revoked in 
     accordance with law by the President, the Secretary, or other 
     authorized official, a court of competent jurisdiction, or by 
     operation of law.
       (b) Centers for Disease Control and Prevention Office of 
     Women's Health.--Part A of title III (42 U.S.C. 241 et seq.) 
     is amended by adding at the end the following:

     ``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION 
                   OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Director of the Centers for Disease Control and 
     Prevention, an office to be known as the Office of Women's 
     Health (referred to in this section as the `Office'). The 
     Office shall be headed by a director who shall be appointed 
     by the Director of such Centers.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Director of the Centers for Disease 
     Control and Prevention on the current level of the Centers' 
     activity regarding women's health conditions across, where 
     appropriate, age, biological, and sociocultural contexts, in 
     all aspects of the Centers' work, including prevention 
     programs, public and professional education, services, and 
     treatment;
       ``(2) establish short-range and long-range goals and 
     objectives within the Centers for women's health and, as 
     relevant and appropriate, coordinate with other appropriate 
     offices on activities within the Centers that relate to 
     prevention, research, education and training, service 
     delivery, and policy development, for issues of particular 
     concern to women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the Centers;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on the policy of the Centers with regard to 
     women; and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4)).
       ``(c) Definition.--As used in this section, the term 
     `women's health conditions', with respect to women of all 
     age, ethnic, and racial groups, means diseases, disorders, 
     and conditions--
       ``(1) unique to, significantly more serious for, or 
     significantly more prevalent in women; and
       ``(2) for which the factors of medical risk or type of 
     medical intervention are different for women, or for which 
     there is reasonable evidence that indicates that such factors 
     or types may be different for women.''.
       (c) Office of Women's Health Research.--Section 486(a) (42 
     U.S.C. 287d(a)) is amended by inserting ``and who shall 
     report directly to the Director'' before the period at the 
     end thereof.
       (d) Substance Abuse and Mental Health Services 
     Administration.--Section 501(f) (42 U.S.C. 290aa(f)) is 
     amended--
       (1) in paragraph (1), by inserting ``who shall report 
     directly to the Administrator'' before the period;
       (2) by redesignating paragraph (4) as paragraph (5); and
       (3) by inserting after paragraph (3), the following:
       ``(4) Office.--Nothing in this subsection shall be 
     construed to preclude the Secretary from establishing within 
     the Substance Abuse and Mental Health Administration an 
     Office of Women's Health.''.
       (e) Agency for Healthcare Research and Quality Activities 
     Regarding Women's Health.--Part C of title IX (42 U.S.C. 299c 
     et seq.) is amended--
       (1) by redesignating sections 927 and 928 as sections 928 
     and 929, respectively;
       (2) by inserting after section 926 the following:

     ``SEC. 927. ACTIVITIES REGARDING WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Director, an Office of Women's Health and 
     Gender-Based Research (referred to in this section as the 
     `Office'). The Office shall be headed by a director who shall 
     be appointed by the Director of Healthcare and Research 
     Quality.
       ``(b) Purpose.--The official designated under subsection 
     (a) shall--
       ``(1) report to the Director on the current Agency level of 
     activity regarding women's health, across, where appropriate, 
     age, biological, and sociocultural contexts, in all aspects 
     of Agency work, including the development of evidence reports 
     and clinical practice protocols and the conduct of research 
     into patient outcomes, delivery of health care services, 
     quality of care, and access to health care;
       ``(2) establish short-range and long-range goals and 
     objectives within the Agency for research important to 
     women's health and, as relevant and appropriate, coordinate 
     with other appropriate offices on activities within the 
     Agency that relate to health services and medical 
     effectiveness research, for issues of particular concern to 
     women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the Agency;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on Agency policy with regard to women; and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4)).''; and
       (3) by adding at the end of section 928 (as redesignated by 
     paragraph (1)) the following:
       ``(e) Women's Health.--For the purpose of carrying out 
     section 927 regarding women's health, there are authorized to 
     be appropriated such sums as may be necessary for each of 
     fiscal years 2011 through 2015.''.
       (f) Health Resources and Services Administration Office of 
     Women's Health.--Title VII of the Social Security Act (42 
     U.S.C. 901 et seq.) is amended by adding at the end the 
     following:

     ``SEC. 713. OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--The Secretary shall establish within 
     the Office of the Administrator of the Health Resources and 
     Services Administration, an office to be known as the Office 
     of Women's Health. The Office shall be headed by a director 
     who shall be appointed by the Administrator.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Administrator on the current 
     Administration level of activity regarding women's health 
     across, where appropriate, age, biological, and sociocultural 
     contexts;
       ``(2) establish short-range and long-range goals and 
     objectives within the Health Resources and Services 
     Administration for women's health and, as relevant and 
     appropriate, coordinate with other appropriate offices on 
     activities within the Administration that relate to health 
     care provider training, health service delivery, research, 
     and demonstration projects, for issues of particular concern 
     to women;
       ``(3) identify projects in women's health that should be 
     conducted or supported by the bureaus of the Administration;
       ``(4) consult with health professionals, nongovernmental 
     organizations, consumer organizations, women's health 
     professionals, and other individuals and groups, as 
     appropriate, on Administration policy with regard to women; 
     and
       ``(5) serve as a member of the Department of Health and 
     Human Services Coordinating

[[Page 27390]]

     Committee on Women's Health (established under section 
     229(b)(4) of the Public Health Service Act).
       ``(c) Continued Administration of Existing Programs.--The 
     Director of the Office shall assume the authority for the 
     development, implementation, administration, and evaluation 
     of any projects carried out through the Health Resources and 
     Services Administration relating to women's health on the 
     date of enactment of this section.
       ``(d) Definitions.--For purposes of this section:
       ``(1) Administration.--The term `Administration' means the 
     Health Resources and Services Administration.
       ``(2) Administrator.--The term `Administrator' means the 
     Administrator of the Health Resources and Services 
     Administration.
       ``(3) Office.--The term `Office' means the Office of 
     Women's Health established under this section in the 
     Administration.''.
       (g) Food and Drug Administration Office of Women's 
     Health.--Chapter IX of the Federal Food, Drug, and Cosmetic 
     Act (21 U.S.C. 391 et seq.) is amended by adding at the end 
     the following:

     ``SEC. 911. OFFICE OF WOMEN'S HEALTH.

       ``(a) Establishment.--There is established within the 
     Office of the Commissioner, an office to be known as the 
     Office of Women's Health (referred to in this section as the 
     `Office'). The Office shall be headed by a director who shall 
     be appointed by the Commissioner of Food and Drugs.
       ``(b) Purpose.--The Director of the Office shall--
       ``(1) report to the Commissioner of Food and Drugs on 
     current Food and Drug Administration (referred to in this 
     section as the `Administration') levels of activity regarding 
     women's participation in clinical trials and the analysis of 
     data by sex in the testing of drugs, medical devices, and 
     biological products across, where appropriate, age, 
     biological, and sociocultural contexts;
       ``(2) establish short-range and long-range goals and 
     objectives within the Administration for issues of particular 
     concern to women's health within the jurisdiction of the 
     Administration, including, where relevant and appropriate, 
     adequate inclusion of women and analysis of data by sex in 
     Administration protocols and policies;
       ``(3) provide information to women and health care 
     providers on those areas in which differences between men and 
     women exist;
       ``(4) consult with pharmaceutical, biologics, and device 
     manufacturers, health professionals with expertise in women's 
     issues, consumer organizations, and women's health 
     professionals on Administration policy with regard to women;
       ``(5) make annual estimates of funds needed to monitor 
     clinical trials and analysis of data by sex in accordance 
     with needs that are identified; and
       ``(6) serve as a member of the Department of Health and 
     Human Services Coordinating Committee on Women's Health 
     (established under section 229(b)(4) of the Public Health 
     Service Act).''.
       (h) No New Regulatory Authority.--Nothing in this section 
     and the amendments made by this section may be construed as 
     establishing regulatory authority or modifying any existing 
     regulatory authority.
       (i) Limitation on Termination.--Notwithstanding any other 
     provision of law, a Federal office of women's health 
     (including the Office of Research on Women's Health of the 
     National Institutes of Health) or Federal appointive position 
     with primary responsibility over women's health issues 
     (including the Associate Administrator for Women's Services 
     under the Substance Abuse and Mental Health Services 
     Administration) that is in existence on the date of enactment 
     of this section shall not be terminated, reorganized, or have 
     any of its powers or duties transferred unless such 
     termination, reorganization, or transfer is approved by an 
     Act of Congress.
       (j) Rule of Construction.--Nothing in this section (or the 
     amendments made by this section) shall be construed to limit 
     the authority of the Secretary of Health and Human Services 
     with respect to women's health, or with respect to activities 
     carried out through the Department of Health and Human 
     Services on the date of enactment of this section.

     SEC. 2588A. OFFICES OF MINORITY HEALTH

       (a) Existing Office.--Section 1707(a) (42 U.S.C. 300u-6(a)) 
     is amended by striking ``within the Office of Public Health 
     and Science'' and inserting ``within the Office of the 
     Secretary''.
       (b) Additional Offices.--Title XVII (42 U.S.C. 300u et 
     seq.) is amended by inserting after section 1707 the 
     following:

     ``SEC. 1707A. ADDITIONAL OFFICES OF MINORITY HEALTH.

       ``(a) Establishment.--In addition to the Office of Minority 
     Health established within the Office of the Secretary under 
     section 1707, the Secretary shall establish an Office of 
     Minority Health in each of the following agencies:
       ``(1) The Centers for Disease Control and Prevention.
       ``(2) The Substance Abuse and Mental Health Services 
     Administration.
       ``(3) The Agency for Healthcare Research and Quality.
       ``(4) The Health Resources and Services Administration.
       ``(5) The Food and Drug Administration.
       ``(b) Director; Appointment.--Each Office of Minority 
     Health established in an agency listed in subsection (a) 
     shall be headed by a director, who shall be appointed by and 
     report directly to the head of such agency.
       ``(c) References.--Except as otherwise specified, any 
     reference in Federal law to an Office of Minority Health (in 
     the Department of Health and Human Services) is deemed to be 
     a reference to the Office of Minority Health in the Office of 
     the Secretary.''.
       (c) No New Regulatory Authority.--Nothing in this section 
     and the amendments made by this section may be construed as 
     establishing regulatory authority or modifying any existing 
     regulatory authority.
       (d) Limitation on Termination.--Notwithstanding any other 
     provision of law, a Federal office of minority health or 
     Federal appointive position with primary responsibility over 
     minority health issues that is in existence in a office or 
     agency of the Department of Health and Human Services on the 
     date of enactment of this section shall not be terminated, 
     reorganized, or have any of its powers or duties transferred 
     unless such termination, reorganization, or transfer is 
     approved by an Act of Congress.

     SEC. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUPPORT.

       (a) Amendments to the Older Americans Act of 1965.--
       (1) Promotion of direct care workforce.--Section 202(b)(1) 
     of the Older Americans Act of 1965 (42 U.S.C. 3012(b)(1)) is 
     amended by inserting before the semicolon the following: ``, 
     and, in carrying out the purposes of this paragraph, shall 
     make recommendations to other Federal entities regarding 
     appropriate and effective means of identifying, promoting, 
     and implementing investments in the direct care workforce 
     necessary to meet the growing demand for long-term health 
     services and supports and of assisting States in developing a 
     comprehensive State workforce development plan with respect 
     to such workforce, including assisting efforts to 
     systematically assess, track, and report on workforce 
     adequacy and capacity''.
       (2) Personal care attendant workforce advisory panel.--
     Section 202 of such Act (42 U.S.C. 3012) is amended by adding 
     at the end the following:
       ``(g)(1) Not later than 90 days after the date of the 
     enactment of this subsection, the Assistant Secretary shall 
     establish a Personal Care Attendant Workforce Advisory Panel 
     to examine and formulate recommendations on--
       ``(A) working conditions and training for workers providing 
     long-term services and supports, including home health aides, 
     certified nurse aides, and personal care attendants; and
       ``(B) other workforce issues related to such workers, 
     including with respect to the adequacy of the number of such 
     workers; the salaries, wages, and benefits of such workers; 
     and access to the services provided by such workers.
       ``(2) The Panel shall include representatives of--
       ``(A) relevant home- and community-based service providers, 
     health care agencies, and facilities (including personal or 
     home care agencies, home health care agencies, nursing homes, 
     assisted living facilities, and residential care facilities);
       ``(B) the disability community, including individuals with 
     disabilities and family caregivers;
       ``(C) the nursing community;
       ``(D) direct care workers (which may include unions and 
     national organizations);
       ``(E) older individuals, including senior individuals and 
     family caregivers;
       ``(F) State and Federal health care entities; and
       ``(G) experts in workforce development and adult learning.
       ``(3) Within one year after the establishment of the Panel, 
     the Panel shall submit a report to the Assistant Secretary 
     and the Congress on workforce issues related to providing 
     long-term services and supports, including information on 
     core competencies for eligible personal or home care aides 
     necessary to successfully provide long-term services and 
     supports to eligible consumers, as well as recommended 
     training curricula and resources.
       ``(4) Within 180 days after receipt by the Assistant 
     Secretary of the report under paragraph (3), the Assistant 
     Secretary shall establish a 3-year demonstration program in 4 
     States to pilot and evaluate the effectiveness of the 
     competencies articulated by the Panel and the training 
     curricula and training methods recommended by the Panel.
       ``(5) Not later than 1 year after the completion of the 
     demonstration program under paragraph (4), the Assistant 
     Secretary shall submit to the Congress a report containing 
     the results of the evaluations by the Assistant Secretary 
     pursuant to paragraph (4), together with such recommendations 
     for legislation or administrative action as the Assistant 
     Secretary determines appropriate.''.
       (b) Authorization of Additional Appropriations for the 
     Family Caregiver Support Program Under the Older Americans 
     Act of 1965.--Section 303(e)(2) of the Older

[[Page 27391]]

     Americans Act of 1965 (42 U.S.C. 3023(e)(2)) is amended by 
     striking ``, $173,000,000'' and all that follows through 
     ``2011'', and inserting ``and $250,000,000 for each of fiscal 
     years 2011, 2012, and 2013''.

     SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET AND RELATED 
                   EDUCATIONAL AND TRAINING OPPORTUNITIES.

       (a) In General.--The Secretary of Labor, in consultation 
     with the National Center for Health Workforce Analysis, shall 
     establish and maintain a Web site to serve as a comprehensive 
     source of information, searchable by workforce region, on the 
     health care labor market and related educational and training 
     opportunities.
       (b) Contents.--The Web site maintained under this section 
     shall include the following:
       (1) Information on the types of jobs that are currently or 
     are projected to be in high demand in the health care field, 
     including--
       (A) salary information; and
       (B) training requirements, such as requirements for 
     educational credentials, licensure, or certification.
       (2) Information on training and educational opportunities 
     within each region for the type of jobs described in 
     paragraph (1), including by--
       (A) type of provider or program (such as public, private 
     nonprofit, or private for-profit);
       (B) duration;
       (C) cost (such as tuition, fees, books, laboratory 
     expenses, and other mandatory costs);
       (D) performance outcomes (such as graduation rates, job 
     placement, average salary, job retention, and wage 
     progression);
       (E) Federal financial aid participation;
       (F) average graduate loan debt;
       (G) student loan default rates;
       (H) average institutional grant aid provided;
       (I) Federal and State accreditation information; and
       (J) other information determined by the Secretary.
       (3) A mechanism for searching and comparing training and 
     educational options for specific health care occupations to 
     facilitate informed career and education choices.
       (4) Financial aid information, including with respect to 
     loan forgiveness, loan cancellation, loan repayment, 
     stipends, scholarships, and grants or other assistance 
     authorized by this Act or other Federal or State programs.
       (c) Public Accessibility.--The Web site maintained under 
     this section shall--
       (1) be publicly accessible;
       (2) be user friendly and convey information in a manner 
     that is easily understandable; and
       (3) be in English and the second most prevalent language 
     spoken based on the latest Census information.

     SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PROGRAMS.

       Section 171 of the Workforce Investment Act of 1998 (29 
     U.S.C. 2916) is amended by adding at the end the following:
       ``(f) Online Health Workforce Training Program.--
       ``(1) Grant program.--
       ``(A) In general.--The Secretary in consultation with the 
     Secretary of Health and Human Services, shall award National 
     Health Workforce Online Training Grants on a competitive 
     basis to eligible entities to enable such entities to carry 
     out training for individuals to attain or advance in health 
     care occupations. An entity may leverage such grant with 
     other Federal, State, local, and private resources, in order 
     to expand the participation of businesses, employees, and 
     individuals in such training programs.
       ``(B) Eligibility.--In order to receive a grant under the 
     program established under this paragraph--
       ``(i) an entity shall be an educational institution, 
     community-based organization, nonprofit organization, 
     workforce investment board, or local or county government; 
     and
       ``(ii) an entity shall provide online workforce training 
     for individuals seeking to attain or advance in health care 
     occupations, including nursing, nursing assistants, 
     dentistry, pharmacy, health care management and 
     administration, public health, health information systems 
     analysis, medical assistants, and other health care 
     practitioner and support occupations.
       ``(C) Priority.--Priority in awarding grants under this 
     paragraph shall be given to entities that--
       ``(i) have demonstrated experience in implementing and 
     operating online worker skills training and education 
     programs;
       ``(ii) have demonstrated experience coordinating 
     activities, where appropriate, with the workforce investment 
     system; and
       ``(iii) conduct training for occupations with national or 
     local shortages.
       ``(D) Data collection.--Grantees under this paragraph shall 
     collect and report information on--
       ``(i) the number of participants;
       ``(ii) the services received by the participants;
       ``(iii) program completion rates;
       ``(iv) factors determined as significantly interfering with 
     program participation or completion;
       ``(v) the rate of job placement; and
       ``(vi) other information as determined as needed by the 
     Secretary.
       ``(E) Outreach.--Grantees under this paragraph shall 
     conduct outreach activities to disseminate information about 
     their program and results to workforce investment boards, 
     local governments, educational institutions, and other 
     workforce training organizations.
       ``(F) Performance levels.--The Secretary shall establish 
     indicators of performance that will be used to evaluate the 
     performance of grantees under this paragraph in carrying out 
     the activities described in this paragraph. The Secretary 
     shall negotiate and reach agreement with each grantee 
     regarding the levels of performance expected to be achieved 
     by the grantee on the indicators of performance.
       ``(G) Authorization of appropriations.--There are 
     authorized to be appropriated to the Secretary to carry out 
     this subsection $50,000,000 for fiscal years 2011 through 
     2020.
       ``(2) Online health professions training program 
     clearinghouse.--
       ``(A) Description of grant.--The Secretary may award one or 
     more grants to eligible postsecondary educational 
     institutions to provide the services described in this 
     paragraph.
       ``(B) Eligibility.--To be eligible to receive a grant under 
     this paragraph, a postsecondary educational institution 
     shall--
       ``(i) have demonstrated the ability to disseminate research 
     on best practices for implementing workforce investment 
     programs; and
       ``(ii) be a national leader in producing cutting-edge 
     research on technology related to workforce investment 
     systems under subtitle B.
       ``(C) Services.--The postsecondary educational institution 
     that receives a grant under this paragraph shall use such 
     grant--
       ``(i) to provide technical assistance to entities that 
     receive grants under paragraph (1);
       ``(ii) to collect and nationally disseminate the data 
     gathered by entities that receive grants under paragraph (1); 
     and
       ``(iii) to disseminate the best practices identified by the 
     National Health Workforce Online Training Grant Program to 
     other workforce training organizations.
       ``(D) Authorization of appropriations.--There are 
     authorized to be appropriated to the Secretary to carry out 
     this subsection $1,000,000 for fiscal years 2011 through 
     2020.''.

     SEC. 2592. ACCESS FOR INDIVIDUALS WITH DISABILITIES.

       Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et 
     seq.) is amended by adding at the end of the following:

     ``SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC 
                   EQUIPMENT.

       ``(a) Standards.--Not later than 9 months after the date of 
     enactment of the Affordable Health Care for America Act, the 
     Architectural and Transportation Barriers Compliance Board 
     (Access Board) shall issue guidelines setting forth the 
     minimum technical criteria for new medical diagnostic 
     equipment to be purchased for use in (or in conjunction with) 
     physician's offices, clinics, emergency rooms, hospitals, and 
     other medical settings. The guidelines shall ensure that such 
     equipment is accessible to, and usable by, individuals with 
     disabilities, including provisions to ensure independent 
     entry to, use of, and exit from the equipment by such 
     individuals to the maximum extent possible.
       ``(b) Medical Diagnostic Equipment Covered.--The guidelines 
     issued under subsection (a) for medical diagnostic equipment 
     shall apply to new purchases of equipment that includes 
     examination tables, examination chairs (including chairs used 
     for eye examinations or procedures, and dental examinations 
     or procedures), weight scales, mammography equipment, x-ray 
     machines, and other equipment commonly used for diagnostic or 
     examination purposes by health professionals.
       ``(c) Regulations.--Not later than 6 months after the date 
     of the issuance of the guidelines under subsection (a), each 
     appropriate Federal agency authorized to promulgate 
     regulations under this Act or under the Americans with 
     Disabilities Act shall--
       ``(1) prescribe regulations in an accessible format as 
     necessary to carry out the provisions of such Act and section 
     504 of this Act that include accessibility standards that are 
     consistent with the guidelines issued under subsection (a); 
     and
       ``(2) ensure that health care providers and health care 
     plans covered by the Affordable Health Care for America Act 
     meet the requirements of the Americans with Disabilities Act 
     and section 504, including provisions ensuring that 
     individuals with disabilities receive equal access to all 
     aspects of the health care delivery system.
       ``(d) Review and Amend.--The Architectural and 
     Transportation Barriers Compliance Board (Access Board) shall 
     periodically review and, as appropriate, amend the guidelines 
     as prescribed under subsection (a). Not later than 6 months 
     after the date of the issuance of such revised guidelines, 
     revised regulations consistent with such guidelines shall be 
     promulgated in an accessible format by the appropriate 
     Federal agencies described in subsection (c).''.

[[Page 27392]]



     SEC. 2593. DUPLICATIVE GRANT PROGRAMS.

       (a) Study.--The Secretary of Health and Human Services (in 
     this section referred to as the ``Secretary'') shall conduct 
     a study to determine if any new division C grant program is 
     duplicative of one or more other grant programs of the 
     Department of Health and Human Services that--
       (1) are specifically authorized in the Public Health 
     Service Act (42 U.S.C. 201 et seq.); or
       (2) are receiving appropriations.
       (b) Duplicative Programs.--If the Secretary determines 
     under subsection (a) that a new division C grant program is 
     duplicative of one or more other grant programs described in 
     such subsection, the Secretary shall--
       (1) attempt to integrate the new division C grant program 
     with the duplicative programs; and
       (2) if the Secretary determines that such integration is 
     not appropriate or has not been successful, promulgate a rule 
     eliminating the duplication, including, if appropriate, by 
     terminating one or more programs.
       (c) Continued Availability of Funds.--Any funds 
     appropriated to carry out a program that is terminated under 
     subsection (b)(2) shall remain available for obligation for 
     the one or more programs that--
       (1) were determined under subsection (a) to be duplicative 
     of such program; and
       (2) remain in effect.
       (d) Report.--Not later than 1 year after the date of the 
     enactment of this Act, the Secretary shall submit to the 
     Congress and make available to the public a report that 
     contains the results of the study required under subsection 
     (a).
       (e) Congressional Review.--Any rule under subsection (b)(2) 
     terminating a program is deemed to be a major rule for 
     purposes of chapter 8 of title 5, United States Code.
       (f) Definition.--In this section, the term ``new division C 
     grant program''--
       (1) means a grant program first established by this 
     division; and
       (2) excludes any program whose statutory authorization was 
     in existence before the enactment of this division.

     SEC. 2594. DIABETES SCREENING COLLABORATION AND OUTREACH 
                   PROGRAM.

       (a) Establishment.--With respect to diabetes screening 
     tests and for the purposes of reducing the number of 
     undiagnosed seniors with diabetes or prediabetes, the 
     Secretary of Health and Human Services (referred to in this 
     section as the ``Secretary''), in collaboration with the 
     Director of the Centers for Disease Control and Prevention 
     (referred to in this section as the ``Director''), shall--
       (1) review uptake and utilization of diabetes screening 
     benefits, consistent with recommendations of the Task Force 
     on Clinical Preventive Services (established under section 
     3131 of the Public Health Service Act, as added by section 
     2301 of this Act), to identify and address any existing 
     problems, with regard to uptake and utilization and related 
     data collection mechanisms; and
       (2) establish an outreach program to identify existing 
     efforts by agencies of the Department of Health and Human 
     Services and by the private and nonprofit sectors to increase 
     awareness among seniors and providers of diabetes screening 
     benefits.
       (b) Consultation.--The Secretary shall carry out this 
     section in consultation with--
       (1) the heads of appropriate health agencies and offices in 
     the Department of Health and Human Services, including the 
     Office of Minority Health; and
       (2) entities with an interest in diabetes, including 
     industry, voluntary health organizations, trade associations, 
     and professional societies.
       (c) Report.--The Secretary shall submit an annual report to 
     the Congress on the activities carried out under this 
     section.

     SEC. 2595. IMPROVEMENT OF VITAL STATISTICS COLLECTION.

       (a) In General.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary''), acting 
     through the Director of the Centers for Disease Control and 
     Prevention and in collaboration with appropriate agencies and 
     States, shall--
       (1) promote the education and training of physicians on the 
     importance of birth and death certification data and how to 
     properly complete these documents in accordance with State 
     law, including the collection of such data for diabetes and 
     other chronic diseases as appropriate;
       (2) encourage State adoption of the latest standard 
     revisions of birth and death certificates; and
       (3) work with States to re-engineer their vital statistics 
     systems in order to provide cost-effective, timely, and 
     accurate vital systems data.
       (b) Death Certificate Additional Language.--In carrying out 
     this section, the Secretary may promote improvements to the 
     collection of diabetes mortality data, including, as 
     appropriate, the addition by States of a question for the 
     individual certifying the cause of death regarding whether 
     the deceased had diabetes.

     SEC. 2596. NATIONAL HEALTH SERVICES CORPS DEMONSTRATION ON 
                   INCENTIVE PAYMENTS.

       (a) In General.--The Secretary of Health and Human Services 
     may establish a demonstration program under which, in 
     addition to the salary and benefits otherwise owed to a 
     member of the National Health Services Corps, incentive 
     payments are awarded to any such member who is assigned to a 
     health professional shortage area with extreme need.
       (b) Report.--The Secretary shall submit to the Congress an 
     annual report on the demonstration program under subsection 
     (a).
       (c) Definitions.--In this section:
       (1) The term ``health professional shortage area with 
     extreme need'' means a health professional shortage area 
     that--
       (A) is described in section 333A(a)(1)(A) of the Public 
     Health Service Act (42 U.S.C. 254f-1(a)(1)(A));
       (B) is described in section 333(a)(1)(D)(ii)(IV) of such 
     Act (42 U.S.C. 254f(a)(1)(D)(ii)(IV)); and
       (C) has high rates of untreated disease, including chronic 
     conditions.
       (3) The term ``Secretary'' means the Secretary of Health 
     and Human Services.
       (d) Authorization of Appropriations.--To carry out this 
     section, there are authorized to be appropriated such sums as 
     may be necessary for each of fiscal years 2011 through 2015.

               DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

     SEC. 3001. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This division may be cited as the 
     ``Indian Health Care Improvement Act Amendments of 2009''.
       (b) Table of Contents.--The table of contents of this 
     division is as follows:
Sec. 3001. Short title; table of contents.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

Sec. 3101. Indian Health Care Improvement Act amended.
Sec. 3102. Native American Health and Wellness Foundation.
Sec. 3103. GAO study and report on payments for contract health 
              services.

 TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL 
                              SECURITY ACT

Sec. 3201. Expansion of payments under Medicare, Medicaid, and SCHIP 
              for all covered services furnished by Indian Health 
              Programs.
Sec. 3202. Additional provisions to increase outreach to, and 
              enrollment of, Indians in SCHIP and Medicaid.
Sec. 3203. Solicitation of proposals for safe harbors under the Social 
              Security Act for facilities of Indian Health Programs and 
              urban Indian organizations.
Sec. 3204. Annual report on Indians served by Social Security Act 
              health benefit programs.
Sec. 3205. Development of recommendations to improve interstate 
              coordination of Medicaid and SCHIP coverage of Indian 
              children and other children who are outside of their 
              State of residency because of educational or other needs.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

     SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.

       (a) In General.--The Indian Health Care Improvement Act (25 
     U.S.C. 1601 et seq.) is amended to read as follows:

     ``SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

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

``Sec. 1. Short title; table of contents.
``Sec. 2. Findings.
``Sec. 3. Declaration of national Indian health policy.
``Sec. 4. Definitions.

       ``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

``Sec. 101. Purpose.
``Sec. 102. Health professions recruitment program for Indians.
``Sec. 103. Health professions preparatory scholarship program for 
              Indians.
``Sec. 104. Indian health professions scholarships.
``Sec. 105. American Indians Into Psychology Program.
``Sec. 106. Scholarship programs for Indian Tribes.
``Sec. 107. Indian Health Service extern programs.
``Sec. 108. Continuing education allowances.
``Sec. 109. Community Health Representative Program.
``Sec. 110. Indian Health Service Loan Repayment Program.
``Sec. 111. Scholarship and Loan Repayment Recovery Fund.
``Sec. 112. Recruitment activities.
``Sec. 113. Indian recruitment and retention program.
``Sec. 114. Advanced training and research.
``Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
``Sec. 116. Tribal cultural orientation.
``Sec. 117. INMED Program.
``Sec. 118. Health training programs of community colleges.

[[Page 27393]]

``Sec. 119. Retention bonus.
``Sec. 120. Nursing residency program.
``Sec. 121. Community Health Aide Program.
``Sec. 122. Tribal Health Program administration.
``Sec. 123. Health professional chronic shortage demonstration 
              programs.
``Sec. 124. National Health Service Corps.
``Sec. 125. Substance abuse counselor educational curricula 
              demonstration programs.
``Sec. 126. Behavioral health training and community education 
              programs.
``Sec. 127. Exemption from payment of certain fees.
``Sec. 128. Authorization of appropriations.

                      ``TITLE II--HEALTH SERVICES

``Sec. 201. Indian Health Care Improvement Fund.
``Sec. 202. Health promotion and disease prevention services.
``Sec. 203. Diabetes prevention, treatment, and control.
``Sec. 204. Shared services for long-term care.
``Sec. 205. Health services research.
``Sec. 206. Mammography and other cancer screening.
``Sec. 207. Patient travel costs.
``Sec. 208. Epidemiology centers.
``Sec. 209. Comprehensive school health education programs.
``Sec. 210. Indian youth program.
``Sec. 211. Prevention, control, and elimination of communicable and 
              infectious diseases.
``Sec. 212. Other authority for provision of services.
``Sec. 213. Indian women's health care.
``Sec. 214. Environmental and nuclear health hazards.
``Sec. 215. Arizona as a contract health service delivery area.
``Sec. 216. North Dakota and South Dakota as contract health service 
              delivery area.
``Sec. 217. California contract health services program.
``Sec. 218. California as a contract health service delivery area.
``Sec. 219. Contract health services for the Trenton Service Area.
``Sec. 220. Programs operated by Indian Tribes and tribal 
              organizations.
``Sec. 221. Licensing.
``Sec. 222. Notification of provision of emergency contract health 
              services.
``Sec. 223. Prompt action on payment of claims.
``Sec. 224. Liability for payment.
``Sec. 225. Office of Indian Men's Health.
``Sec. 226. Catastrophic health emergency fund.
``Sec. 227. Authorization of appropriations.

                        ``TITLE III--FACILITIES

``Sec. 301. Consultation; construction and renovation of facilities; 
              reports.
``Sec. 302. Sanitation facilities.
``Sec. 303. Preference to Indians and Indian firms.
``Sec. 304. Expenditure of non-Service funds for renovation.
``Sec. 305. Funding for the construction, expansion, and modernization 
              of small ambulatory care facilities.
``Sec. 306. Indian health care delivery demonstration project.
``Sec. 307. Land transfer.
``Sec. 308. Leases, contracts, and other agreements.
``Sec. 309. Study on loans, loan guarantees, and loan repayment.
``Sec. 310. Tribal leasing.
``Sec. 311. Indian Health Service/tribal facilities joint venture 
              program.
``Sec. 312. Location of facilities.
``Sec. 313. Maintenance and improvement of health care facilities.
``Sec. 314. Tribal management of federally owned quarters.
``Sec. 315. Applicability of Buy American Act requirement.
``Sec. 316. Other funding for facilities.
``Sec. 317. Authorization of appropriations.

                 ``TITLE IV--ACCESS TO HEALTH SERVICES

``Sec. 401. Treatment of payments under Social Security Act health 
              benefits programs.
``Sec. 402. Grants to and contracts with the Service, Indian Tribes, 
              Tribal Organizations, and urban Indian organizations to 
              facilitate outreach, enrollment, and coverage of Indians 
              under Social Security Act health benefit programs.
``Sec. 403. Reimbursement from certain third parties of costs of health 
              services.
``Sec. 404. Crediting of reimbursements.
``Sec. 405. Purchasing health care coverage.
``Sec. 406. Sharing arrangements with Federal agencies.
``Sec. 407. Eligible indian veteran services.
``Sec. 408. Payor of last resort.
``Sec. 409. Consultation.
``Sec. 410. State Children's Health Insurance Program (SCHIP).
``Sec. 411. Premium and cost sharing protections and eligibility 
              determinations under Medicaid and SCHIP and protection of 
              certain Indian property from Medicaid estate recovery.
``Sec. 412. Treatment under Medicaid and SCHIP managed care.
``Sec. 413. Navajo Nation Medicaid Agency feasibility study.
``Sec. 414. Exception for excepted benefits.
``Sec. 415. Authorization of appropriations.

              ``TITLE V--HEALTH SERVICES FOR URBAN INDIANS

``Sec. 501. Purpose.
``Sec. 502. Contracts with, and grants to, urban Indian organizations.
``Sec. 503. Contracts and grants for the provision of health care and 
              referral services.
``Sec. 504. Use of Federal Government Facilities and Sources of Supply.
``Sec. 505. Contracts and grants for the determination of unmet health 
              care needs.
``Sec. 506. Evaluations; renewals.
``Sec. 507. Other contract and grant requirements.
``Sec. 508. Reports and records.
``Sec. 509. Limitation on contract authority.
``Sec. 510. Facilities.
``Sec. 511. Division of Urban Indian Health.
``Sec. 512. Grants for alcohol and substance abuse-related services.
``Sec. 513. Treatment of certain demonstration projects.
``Sec. 514. Urban NIAAA transferred programs.
``Sec. 515. Conferring with urban Indian organizations.
``Sec. 516. Urban youth treatment center demonstration.
``Sec. 517. Grants for diabetes prevention, treatment, and control.
``Sec. 518. Community health representatives.
``Sec. 519. Effective date.
``Sec. 520. Eligibility for services.
``Sec. 521. Authorization of appropriations.
``Sec. 522. Health information technology.

                ``TITLE VI--ORGANIZATIONAL IMPROVEMENTS

``Sec. 601. Establishment of the Indian Health Service as an agency of 
              the Public Health Service.
``Sec. 602. Automated management information system.
``Sec. 603. Authorization of appropriations.

                ``TITLE VII--BEHAVIORAL HEALTH PROGRAMS

``Sec. 701. Behavioral health prevention and treatment services.
``Sec. 702. Memoranda of agreement with the Department of the Interior.
``Sec. 703. Comprehensive behavioral health prevention and treatment 
              program.
``Sec. 704. Mental health technician program.
``Sec. 705. Licensing requirement for mental health care workers.
``Sec. 706. Indian women treatment programs.
``Sec. 707. Indian youth program.
``Sec. 708. Indian youth telemental health demonstration project.
``Sec. 709. Inpatient and community-based mental health facilities 
              design, construction, and staffing.
``Sec. 710. Training and community education.
``Sec. 711. Behavioral health program.
``Sec. 712. Fetal alcohol disorder programs.
``Sec. 713. Child sexual abuse and prevention treatment programs.
``Sec. 714. Domestic and sexual violence prevention and treatment.
``Sec. 715. Behavioral health research.
``Sec. 716. Definitions.
``Sec. 717. Authorization of appropriations.

                      ``TITLE VIII--MISCELLANEOUS

``Sec. 801. Reports.
``Sec. 802. Regulations.
``Sec. 803. Plan of implementation.
``Sec. 804. Limitation on use of funds appropriated to Indian Health 
              Service.
``Sec. 805. Eligibility of California Indians.
``Sec. 806. Health services for ineligible persons.
``Sec. 807. Reallocation of base resources.
``Sec. 808. Results of demonstration projects.
``Sec. 809. Moratorium.
``Sec. 810. Severability provisions.
``Sec. 811. Use of patient safety organizations.
``Sec. 812. Confidentiality of medical quality assurance records; 
              qualified immunity for participants.
``Sec. 813. Claremore Indian Hospital.
``Sec. 814. Sense of Congress regarding law enforcement and 
              methamphetamine issues in Indian country.
``Sec. 815. Permitting implementation through contracts with Tribal 
              Health Programs.
``Sec. 816. Authorization of appropriations; availability.

     ``SEC. 2. FINDINGS.

       ``Congress makes the following findings:
       ``(1) Federal health services to maintain and improve the 
     health of the Indians are consonant with and required by the 
     Federal Government's historical and unique legal relationship 
     with, and resulting responsibility to, the American Indian 
     people.
       ``(2) A major national goal of the United States is to 
     provide the resources, processes, and structure that will 
     enable Indian tribes

[[Page 27394]]

     and tribal members to obtain the quantity and quality of 
     health care services and opportunities that will eradicate 
     the health disparities between Indians the general 
     population.
       ``(3) A major national goal of the United States is to 
     provide the quantity and quality of health services which 
     will permit the health status of Indians to be raised to the 
     highest possible level and to encourage the maximum 
     participation of Indians in the planning and management of 
     those services.
       ``(4) Federal health services to Indians have resulted in a 
     reduction in the prevalence and incidence of preventable 
     illnesses among, and unnecessary and premature deaths of, 
     Indians.
       ``(5) Despite such services, the unmet health needs of the 
     American Indian people are severe and the health status of 
     the Indians is far below that of the general population of 
     the United States.

     ``SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

       ``Congress declares that it is the policy of this Nation, 
     in fulfillment of its special trust responsibilities and 
     legal obligations to Indians--
       ``(1) to assure the highest possible health status for 
     Indians and Urban Indians and to provide all resources 
     necessary to effect that policy;
       ``(2) to raise the health status of Indians and Urban 
     Indians to at least the levels set forth in the goals 
     contained within the Health People 2010 or successor 
     objectives;
       ``(3) to the greatest extent possible, to allow Indians to 
     set their own health care priorities and establish goals that 
     reflect their unmet needs;
       ``(4) to increase the proportion of all degrees in the 
     health professions and allied and associated health 
     professions awarded to Indians so that the proportion of 
     Indian health professionals in each Service Area is raised to 
     at least the level of that of the general population;
       ``(5) to require meaningful consultation with Indian 
     Tribes, Tribal Organizations, and urban Indian organizations 
     to implement this Act and the national policy of Indian self-
     determination; and
       ``(6) to provide funding for programs and facilities 
     operated by Indian Tribes, Tribal Organizations, and Urban 
     Indian Organizations in amounts that are not less than the 
     amounts provided to programs and facilities operated directly 
     by the Service.

     ``SEC. 4. DEFINITIONS.

       ``For purposes of this Act:
       ``(1) The term `accredited and accessible' means on or near 
     a reservation and accredited by a national or regional 
     organization with accrediting authority.
       ``(2) The term `Area Office' means an administrative 
     entity, including a program office, within the Service 
     through which services and funds are provided to the Service 
     Units within a defined geographic area.
       ``(3) The term `Assistant Secretary' means the Assistant 
     Secretary of Indian Health.
       ``(4)(A) The term `behavioral health' means the blending of 
     substance (including alcohol, drugs, inhalants, and tobacco) 
     abuse and mental health prevention and treatment, for the 
     purpose of providing comprehensive services.
       ``(B) The term `behavioral health' includes the joint 
     development of substance abuse and mental health treatment 
     planning and coordinated case management using a 
     multidisciplinary approach.
       ``(5) The term `California Indians' means those Indians who 
     are eligible for health services of the Service pursuant to 
     section 805.
       ``(6) The term `community college' means--
       ``(A) a tribal college or university, or
       ``(B) a junior or community college.
       ``(7) The term `contract health service' means health 
     services provided at the expense of the Service or a Tribal 
     Health Program by public or private medical providers or 
     hospitals, other than the Service Unit or the Tribal Health 
     Program at whose expense the services are provided.
       ``(8) The term `Department' means, unless otherwise 
     designated, the Department of Health and Human Services.
       ``(9) The term `disease prevention' means the reduction, 
     limitation, and prevention of disease and its complications 
     and reduction in the consequences of disease, including--
       ``(A) controlling--
       ``(i) the development of diabetes;
       ``(ii) high blood pressure;
       ``(iii) infectious agents;
       ``(iv) injuries;
       ``(v) occupational hazards and disabilities;
       ``(vi) sexually transmittable diseases; and
       ``(vii) toxic agents; and
       ``(B) providing--
       ``(i) fluoridation of water; and
       ``(ii) immunizations.
       ``(10) The term `health profession' means allopathic 
     medicine, family medicine, internal medicine, pediatrics, 
     geriatric medicine, obstetrics and gynecology, podiatric 
     medicine, nursing, public health nursing, dentistry, 
     psychiatry, osteopathy, optometry, pharmacy, psychology, 
     public health, social work, marriage and family therapy, 
     chiropractic medicine, environmental health and engineering, 
     allied health professions, naturopathic medicine, and any 
     other health profession.
       ``(11) The term `health promotion' means--
       ``(A) fostering social, economic, environmental, and 
     personal factors conducive to health, including raising 
     public awareness about health matters and enabling the people 
     to cope with health problems by increasing their knowledge 
     and providing them with valid information;
       ``(B) encouraging adequate and appropriate diet, exercise, 
     and sleep;
       ``(C) promoting education and work in conformity with 
     physical and mental capacity;
       ``(D) making available safe water and sanitary facilities;
       ``(E) improving the physical, economic, cultural, 
     psychological, and social environment;
       ``(F) promoting culturally competent care; and
       ``(G) providing adequate and appropriate programs, which 
     may include--
       ``(i) abuse prevention (mental and physical);
       ``(ii) community health;
       ``(iii) community safety;
       ``(iv) consumer health education;
       ``(v) diet and nutrition;
       ``(vi) immunization and other prevention of communicable 
     diseases, including HIV/AIDS;
       ``(vii) environmental health;
       ``(viii) exercise and physical fitness;
       ``(ix) avoidance of fetal alcohol disorders;
       ``(x) first aid and CPR education;
       ``(xi) human growth and development;
       ``(xii) injury prevention and personal safety;
       ``(xiii) behavioral health;
       ``(xiv) monitoring of disease indicators between health 
     care provider visits, through appropriate means, including 
     Internet-based health care management systems;
       ``(xv) personal health and wellness practices;
       ``(xvi) personal capacity building;
       ``(xvii) prenatal, pregnancy, and infant care;
       ``(xviii) psychological well-being;
       ``(xix) reproductive health and family planning;
       ``(xx) safe and adequate water;
       ``(xxi) healthy work environments;
       ``(xxii) elimination, reduction, and prevention of 
     contaminants that create unhealthy household conditions 
     (including mold and other allergens);
       ``(xxiii) stress control;
       ``(xxiv) substance abuse;
       ``(xxv) sanitary facilities;
       ``(xxvi) sudden infant death syndrome prevention;
       ``(xxvii) tobacco use cessation and reduction;
       ``(xxviii) violence prevention; and
       ``(xxix) activities to promote achievement of any of the 
     objectives described in section 3(2).
       ``(12) The term `Indian', unless otherwise designated, 
     means any person who is a member of an Indian Tribe or is 
     eligible for health services under section 805, except that, 
     for the purpose of sections 102 and 103, the term also means 
     any individual who--
       ``(A)(i) irrespective of whether the individual lives on or 
     near a reservation, is a member of a tribe, band, or other 
     organized group of Indians, including those tribes, bands, or 
     groups terminated since 1940 and those recognized now or in 
     the future by the State in which they reside; or
       ``(ii) is a descendant, in the first or second degree, of 
     any such member;
       ``(B) is an Eskimo or Aleut or other Alaska Native;
       ``(C) is considered by the Secretary of the Interior to be 
     an Indian for any purpose; or
       ``(D) is determined to be an Indian under regulations 
     promulgated by the Secretary.
       ``(13) The term `Indian Health Program' means--
       ``(A) any health program administered directly by the 
     Service;
       ``(B) any Tribal Health Program; or
       ``(C) any Indian Tribe or Tribal Organization to which the 
     Secretary provides funding pursuant to section 23 of the Act 
     of June 25, 1910 (25 U.S.C. 47) (commonly known as the `Buy 
     Indian Act').
       ``(14) The term `Indian Tribe' has the meaning given the 
     term in the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.).
       ``(15) The term `junior or community college' has the 
     meaning given the term by section 312(f) of the Higher 
     Education Act of 1965 (20 U.S.C. 1058(f)).
       ``(16) The term `reservation' means any federally 
     recognized Indian Tribe's reservation, Pueblo, or colony, 
     including former reservations in Oklahoma, Indian allotments, 
     and Alaska Native Regions established pursuant to the Alaska 
     Native Claims Settlement Act (43 U.S.C. 1601 et seq.).
       ``(17) The term `Secretary', unless otherwise designated, 
     means the Secretary of Health and Human Services.
       ``(18) The term `Service' means the Indian Health Service.
       ``(19) The term `Service Area' means the geographical area 
     served by each Area Office.
       ``(20) The term `Service Unit' means an administrative 
     entity of the Service, or a Tribal Health Program through 
     which services are provided, directly or by contract, to 
     eligible Indians within a defined geographic area.
       ``(21) The term `telehealth' has the meaning given the term 
     in section 330K(a) of the

[[Page 27395]]

     Public Health Service Act (42 U.S.C. 254c-16(a)).
       ``(22) The term `telemedicine' means a telecommunications 
     link to an end user through the use of eligible equipment 
     that electronically links health professionals or patients 
     and health professionals at separate sites in order to 
     exchange health care information in audio, video, graphic, or 
     other format for the purpose of providing improved health 
     care services.
       ``(23) The term `tribal college or university' has the 
     meaning given the term in section 316(b)(3) of the Higher 
     Education Act (20 U.S.C. 1059c(b)(3)).
       ``(24) The term `Tribal Health Program' means an Indian 
     Tribe or Tribal Organization that operates any health 
     program, service, function, activity, or facility funded, in 
     whole or part, by the Service through, or provided for in, a 
     contract or compact with the Service under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.).
       ``(25) The term `Tribal Organization' has the meaning given 
     the term in the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.).
       ``(26) The term `Urban Center' means any community which 
     has a sufficient Urban Indian population with unmet health 
     needs to warrant assistance under title V of this Act, as 
     determined by the Secretary.
       ``(27) The term `Urban Indian' means any individual who 
     resides in an Urban Center and who meets 1 or more of the 
     following criteria:
       ``(A) Irrespective of whether the individual lives on or 
     near a reservation, the individual is a member of a tribe, 
     band, or other organized group of Indians, including those 
     tribes, bands, or groups terminated since 1940 and those 
     tribes, bands, or groups that are recognized by the States in 
     which they reside, or who is a descendant in the first or 
     second degree of any such member.
       ``(B) The individual is an Eskimo, Aleut, or other Alaska 
     Native.
       ``(C) The individual is considered by the Secretary of the 
     Interior to be an Indian for any purpose.
       ``(D) The individual is determined to be an Indian under 
     regulations promulgated by the Secretary.
       ``(28) The term `urban Indian organization' means a 
     nonprofit corporate body that (A) is situated in an Urban 
     Center; (B) is governed by an Urban Indian-controlled board 
     of directors; (C) provides for the participation of all 
     interested Indian groups and individuals; and (D) is capable 
     of legally cooperating with other public and private entities 
     for the purpose of performing the activities described in 
     section 503(a).

       ``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

     ``SEC. 101. PURPOSE.

       ``The purpose of this title is to increase, to the maximum 
     extent feasible, the number of Indians entering the health 
     professions and providing health services, and to assure an 
     optimum supply of health professionals to the Indian Health 
     Programs and urban Indian organizations involved in the 
     provision of health services to Indians.

     ``SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR 
                   INDIANS.

       ``(a) In General.--The Secretary, acting through the 
     Service, shall make grants to public or nonprofit private 
     health or educational entities, Tribal Health Programs, or 
     urban Indian organizations to assist such entities in meeting 
     the costs of--
       ``(1) identifying Indians with a potential for education or 
     training in the health professions and encouraging and 
     assisting them--
       ``(A) to enroll in courses of study in such health 
     professions; or
       ``(B) if they are not qualified to enroll in any such 
     courses of study, to undertake such postsecondary education 
     or training as may be required to qualify them for 
     enrollment;
       ``(2) publicizing existing sources of financial aid 
     available to Indians enrolled in any course of study referred 
     to in paragraph (1) or who are undertaking training necessary 
     to qualify them to enroll in any such course of study; or
       ``(3) establishing other programs which the Secretary 
     determines will enhance and facilitate the enrollment of 
     Indians in, and the subsequent pursuit and completion by them 
     of, courses of study referred to in paragraph (1).
       ``(b) Grants.--
       ``(1) Application.--No grant may be made under this section 
     unless an application has been submitted to, and approved by, 
     the Secretary. Such application shall be in such form, 
     submitted in such manner, and contain such information, as 
     the Secretary shall by regulation prescribe pursuant to this 
     Act. The Secretary shall give a preference to applications 
     submitted by Tribal Health Programs or urban Indian 
     organizations.
       ``(2) Amount of grants; payment.--The amount of a grant 
     under this section shall be determined by the Secretary. 
     Payments pursuant to this section may be made in advance or 
     by way of reimbursement, and at such intervals and on such 
     conditions as provided for in regulations issued pursuant to 
     this Act. To the extent not otherwise prohibited by law, 
     grants shall be for 3 years, as provided in regulations 
     issued pursuant to this Act.

     ``SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP 
                   PROGRAM FOR INDIANS.

       ``(a) Scholarships Authorized.--The Secretary, acting 
     through the Service, shall provide scholarship grants to 
     Indians who--
       ``(1) have successfully completed their high school 
     education or high school equivalency; and
       ``(2) have demonstrated the potential to successfully 
     complete courses of study in the health professions.
       ``(b) Purposes.--Scholarship grants provided pursuant to 
     this section shall be for the following purposes:
       ``(1) Compensatory preprofessional education of any 
     recipient, such scholarship not to exceed 2 years on a full-
     time basis (or the part-time equivalent thereof, as 
     determined by the Secretary pursuant to regulations issued 
     under this Act).
       ``(2) Pregraduate education of any recipient leading to a 
     baccalaureate degree in an approved course of study 
     preparatory to a field of study in a health profession, such 
     scholarship not to exceed 4 years. An extension of up to 2 
     years (or the part-time equivalent thereof, as determined by 
     the Secretary pursuant to regulations issued pursuant to this 
     Act) may be approved.
       ``(c) Other Conditions.--Scholarships under this section--
       ``(1) may cover costs of tuition, books, transportation, 
     board, and other necessary related expenses of a recipient 
     while attending school;
       ``(2) shall not be denied solely on the basis of the 
     applicant's scholastic achievement if such applicant has been 
     admitted to, or maintained good standing at, an accredited 
     institution; and
       ``(3) shall not be denied solely by reason of such 
     applicant's eligibility for assistance or benefits under any 
     other Federal program.

     ``SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

       ``(a) In General.--
       ``(1) Authority.--The Secretary, acting through the 
     Service, shall make scholarship grants to Indians who are 
     enrolled full or part time in accredited schools pursuing 
     courses of study in the health professions. Such scholarships 
     shall be designated Indian Health Scholarships and shall be 
     made in accordance with section 338A of the Public Health 
     Services Act (42 U.S.C. 254l), except as provided in 
     subsection (b) of this section.
       ``(2) Determinations by secretary.--The Secretary, acting 
     through the Service, shall determine--
       ``(A) who shall receive scholarship grants under subsection 
     (a); and
       ``(B) the distribution of the scholarships among health 
     professions on the basis of the relative needs of Indians for 
     additional service in the health professions.
       ``(3) Certain delegation not allowed.--The administration 
     of this section shall be a responsibility of the Assistant 
     Secretary and shall not be delegated in a contract or compact 
     under the Indian Self-Determination and Education Assistance 
     Act (25 U.S.C. 450 et seq.).
       ``(b) Active Duty Service Obligation.--
       ``(1) Obligation met.--The active duty service obligation 
     under a written contract with the Secretary under this 
     section that an Indian has entered into shall, if that 
     individual is a recipient of an Indian Health Scholarship, be 
     met in full-time practice equal to 1 year for each school 
     year for which the participant receives a scholarship award 
     under this part, or 2 years, whichever is greater, by service 
     in 1 or more of the following:
       ``(A) In an Indian Health Program.
       ``(B) In a program assisted under title V of this Act.
       ``(C) In the private practice of the applicable profession 
     if, as determined by the Secretary, in accordance with 
     guidelines promulgated by the Secretary, such practice is 
     situated in a physician or other health professional shortage 
     area and addresses the health care needs of a substantial 
     number of Indians.
       ``(D) In a teaching capacity in a tribal college or 
     university nursing program (or a related health profession 
     program) if, as determined by the Secretary, the health 
     service provided to Indians would not decrease.
       ``(2) Obligation deferred.--At the request of any 
     individual who has entered into a contract referred to in 
     paragraph (1) and who receives a health professions degree 
     requiring postgraduate training for licensure or to improve 
     clinical skills, the Secretary shall defer the active duty 
     service obligation of that individual under that contract, in 
     order that such individual may complete any internship, 
     residency, or other advanced clinical training that is 
     required for the practice of that health profession, for an 
     appropriate period (in years, as determined by the 
     Secretary), subject to the following conditions:
       ``(A) No period of internship, residency, or other advanced 
     clinical training shall be counted as satisfying any period 
     of obligated service under this subsection.
       ``(B) The active duty service obligation of that individual 
     shall commence not later than 90 days after the completion of 
     that advanced clinical training (or by a date specified by 
     the Secretary).
       ``(C) The active duty service obligation will be served in 
     the health profession of

[[Page 27396]]

     that individual in a manner consistent with paragraph (1).
       ``(D) A recipient of a scholarship under this section may, 
     at the election of the recipient, meet the active duty 
     service obligation described in paragraph (1) by service in a 
     program specified under that paragraph that--
       ``(i) is located on the reservation of the Indian Tribe in 
     which the recipient is enrolled; or
       ``(ii) serves the Indian Tribe in which the recipient is 
     enrolled.
       ``(3) Priority when making assignments.--Subject to 
     paragraph (2), the Secretary, in making assignments of Indian 
     Health Scholarship recipients required to meet the active 
     duty service obligation described in paragraph (1), shall 
     give priority to assigning individuals to service in those 
     programs specified in paragraph (1) that have a need for 
     health professionals to provide health care services as a 
     result of individuals having breached contracts entered into 
     under this section.
       ``(c) Part-time Students.--In the case of an individual 
     receiving a scholarship under this section who is enrolled 
     part time in an approved course of study--
       ``(1) such scholarship shall be for a period of years not 
     to exceed the part-time equivalent of 4 years, as determined 
     by the Secretary;
       ``(2) the period of obligated service described in 
     subsection (b)(1) shall be equal to the greater of--
       ``(A) the part-time equivalent of 1 year for each year for 
     which the individual was provided a scholarship (as 
     determined by the Secretary); or
       ``(B) 2 years; and
       ``(3) the amount of the monthly stipend specified in 
     section 338A(g)(1)(B) of the Public Health Service Act (42 
     U.S.C. 254l(g)(1)(B)) shall be reduced pro rata (as 
     determined by the Secretary) based on the number of hours 
     such student is enrolled.
       ``(d) Breach of Contract.--
       ``(1) Specified breaches.--An individual shall be liable to 
     the United States for the amount which has been paid to the 
     individual, or on behalf of the individual, under a contract 
     entered into with the Secretary under this section on or 
     after the date of enactment of the Indian Health Care 
     Improvement Act Amendments of 2009 if that individual--
       ``(A) fails to maintain an acceptable level of academic 
     standing in the educational institution in which he or she is 
     enrolled (such level determined by the educational 
     institution under regulations of the Secretary);
       ``(B) is dismissed from such educational institution for 
     disciplinary reasons;
       ``(C) voluntarily terminates the training in such an 
     educational institution for which he or she is provided a 
     scholarship under such contract before the completion of such 
     training; or
       ``(D) fails to accept payment, or instructs the educational 
     institution in which he or she is enrolled not to accept 
     payment, in whole or in part, of a scholarship under such 
     contract, in lieu of any service obligation arising under 
     such contract.
       ``(2) Other breaches.--If for any reason not specified in 
     paragraph (1) an individual breaches a written contract by 
     failing either to begin such individual's service obligation 
     required under such contract or to complete such service 
     obligation, the United States shall be entitled to recover 
     from the individual an amount determined in accordance with 
     the formula specified in subsection (l) of section 110 in the 
     manner provided for in such subsection.
       ``(3) Cancellation upon death of recipient.--Upon the death 
     of an individual who receives an Indian Health Scholarship, 
     any outstanding obligation of that individual for service or 
     payment that relates to that scholarship shall be canceled.
       ``(4) Waivers and suspensions.--The Secretary shall provide 
     for the partial or total waiver or suspension of any 
     obligation of service or payment of a recipient of an Indian 
     Health Scholarship if the Secretary determines that--
       ``(A) it is not possible for the recipient to meet that 
     obligation or make that payment;
       ``(B) requiring that recipient to meet that obligation or 
     make that payment would result in extreme hardship to the 
     recipient; or
       ``(C) the enforcement of the requirement to meet the 
     obligation or make the payment would be unconscionable.
       ``(5) Extreme hardship.--Notwithstanding any other 
     provision of law, in any case of extreme hardship or for 
     other good cause shown, the Secretary may waive, in whole or 
     in part, the right of the United States to recover funds made 
     available under this section.
       ``(6) Bankruptcy.--Notwithstanding any other provision of 
     law, with respect to a recipient of an Indian Health 
     Scholarship, no obligation for payment may be released by a 
     discharge in bankruptcy under title 11, United States Code, 
     unless that discharge is granted after the expiration of the 
     5-year period beginning on the initial date on which that 
     payment is due, and only if the bankruptcy court finds that 
     the nondischarge of the obligation would be unconscionable.

     ``SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

       ``(a) Grants Authorized.--The Secretary, acting through the 
     Service, shall make grants of not more than $300,000 to each 
     of 9 colleges and universities for the purpose of developing 
     and maintaining Indian psychology career recruitment programs 
     as a means of encouraging Indians to enter the behavioral 
     health field. These programs shall be located at various 
     locations throughout the country to maximize their 
     availability to Indian students and new programs shall be 
     established in different locations from time to time.
       ``(b) Quentin N. Burdick Program Grant.--The Secretary 
     shall provide a grant authorized under subsection (a) to 
     develop and maintain a program at the University of North 
     Dakota to be known as the `Quentin N. Burdick American 
     Indians Into Psychology Program'. Such program shall, to the 
     maximum extent feasible, coordinate with the Quentin N. 
     Burdick Indian Health Programs authorized under section 
     117(b), the Quentin N. Burdick American Indians Into Nursing 
     Program authorized under section 115(e), and existing 
     university research and communications networks.
       ``(c) Regulations.--The Secretary shall issue regulations 
     pursuant to this Act for the competitive awarding of grants 
     provided under this section.
       ``(d) Conditions of Grant.--Applicants under this section 
     shall agree to provide a program which, at a minimum--
       ``(1) provides outreach and recruitment for health 
     professions to Indian communities including elementary, 
     secondary, and accredited and accessible community colleges 
     that will be served by the program;
       ``(2) incorporates a program advisory board comprised of 
     representatives from the tribes and communities that will be 
     served by the program;
       ``(3) provides summer enrichment programs to expose Indian 
     students to the various fields of psychology through 
     research, clinical, and experimental activities;
       ``(4) provides stipends to undergraduate and graduate 
     students to pursue a career in psychology;
       ``(5) develops affiliation agreements with tribal colleges 
     and universities, the Service, university affiliated 
     programs, and other appropriate accredited and accessible 
     entities to enhance the education of Indian students;
       ``(6) to the maximum extent feasible, uses existing 
     university tutoring, counseling, and student support 
     services; and
       ``(7) to the maximum extent feasible, employs qualified 
     Indians in the program.
       ``(e) Active Duty Service Requirement.--The active duty 
     service obligation prescribed under section 338C of the 
     Public Health Service Act (42 U.S.C. 254m) shall be met by 
     each graduate who receives a stipend described in subsection 
     (d)(4) that is funded under this section. Such obligation 
     shall be met by service--
       ``(1) in an Indian Health Program;
       ``(2) in a program assisted under title V of this Act; or
       ``(3) in the private practice of psychology if, as 
     determined by the Secretary, in accordance with guidelines 
     promulgated by the Secretary, such practice is situated in a 
     physician or other health professional shortage area and 
     addresses the health care needs of a substantial number of 
     Indians.
       ``(f) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     ``SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

       ``(a) In General.--
       ``(1) Grants authorized.--The Secretary, acting through the 
     Service, shall make grants to Tribal Health Programs for the 
     purpose of providing scholarships for Indians to serve as 
     health professionals in Indian communities.
       ``(2) Amount.--Amounts available under paragraph (1) for 
     any fiscal year shall not exceed 5 percent of the amounts 
     available for each fiscal year for Indian Health Scholarships 
     under section 104.
       ``(3) Application.--An application for a grant under 
     paragraph (1) shall be in such form and contain such 
     agreements, assurances, and information as consistent with 
     this section.
       ``(b) Requirements.--
       ``(1) In general.--A Tribal Health Program receiving a 
     grant under subsection (a) shall provide scholarships to 
     Indians in accordance with the requirements of this section.
       ``(2) Costs.--With respect to costs of providing any 
     scholarship pursuant to subsection (a)--
       ``(A) 80 percent of the costs of the scholarship shall be 
     paid from the funds made available pursuant to subsection 
     (a)(1) provided to the Tribal Health Program; and
       ``(B) 20 percent of such costs may be paid from any other 
     source of funds.
       ``(c) Course of Study.--A Tribal Health Program shall 
     provide scholarships under this section only to Indians 
     enrolled or accepted for enrollment in a course of study 
     (approved by the Secretary) in 1 of the health professions 
     contemplated by this Act.
       ``(d) Contract.--
       ``(1) In general.--In providing scholarships under 
     subsection (b), the Secretary and the Tribal Health Program 
     shall enter into a written contract with each recipient of 
     such scholarship.
       ``(2) Requirements.--Such contract shall--
       ``(A) obligate such recipient to provide service in an 
     Indian Health Program or

[[Page 27397]]

     urban Indian organization, in the same Service Area where the 
     Tribal Health Program providing the scholarship is located, 
     for--
       ``(i) a number of years for which the scholarship is 
     provided (or the part-time equivalent thereof, as determined 
     by the Secretary), or for a period of 2 years, whichever 
     period is greater; or
       ``(ii) such greater period of time as the recipient and the 
     Tribal Health Program may agree;
       ``(B) provide that the amount of the scholarship--
       ``(i) may only be expended for--

       ``(I) tuition expenses, other reasonable educational 
     expenses, and reasonable living expenses incurred in 
     attendance at the educational institution; and
       ``(II) payment to the recipient of a monthly stipend of not 
     more than the amount authorized by section 338(g)(1)(B) of 
     the Public Health Service Act (42 U.S.C. 254m(g)(1)(B)), with 
     such amount to be reduced pro rata (as determined by the 
     Secretary) based on the number of hours such student is 
     enrolled, and not to exceed, for any year of attendance for 
     which the scholarship is provided, the total amount required 
     for the year for the purposes authorized in this clause; and

       ``(ii) may not exceed, for any year of attendance for which 
     the scholarship is provided, the total amount required for 
     the year for the purposes authorized in clause (i);
       ``(C) require the recipient of such scholarship to maintain 
     an acceptable level of academic standing as determined by the 
     educational institution in accordance with regulations issued 
     pursuant to this Act; and
       ``(D) require the recipient of such scholarship to meet the 
     educational and licensure requirements appropriate to each 
     health profession.
       ``(3) Service in other service areas.--The contract may 
     allow the recipient to serve in another Service Area, 
     provided the Tribal Health Program and Secretary approve and 
     services are not diminished to Indians in the Service Area 
     where the Tribal Health Program providing the scholarship is 
     located.
       ``(e) Breach of Contract.--
       ``(1) Specific breaches.--An individual who has entered 
     into a written contract with the Secretary and a Tribal 
     Health Program under subsection (d) shall be liable to the 
     United States for the Federal share of the amount which has 
     been paid to him or her, or on his or her behalf, under the 
     contract if that individual--
       ``(A) fails to maintain an acceptable level of academic 
     standing in the educational institution in which he or she is 
     enrolled (such level as determined by the educational 
     institution under regulations of the Secretary);
       ``(B) is dismissed from such educational institution for 
     disciplinary reasons;
       ``(C) voluntarily terminates the training in such an 
     educational institution for which he or she is provided a 
     scholarship under such contract before the completion of such 
     training; or
       ``(D) fails to accept payment, or instructs the educational 
     institution in which he or she is enrolled not to accept 
     payment, in whole or in part, of a scholarship under such 
     contract, in lieu of any service obligation arising under 
     such contract.
       ``(2) Other breaches.--If for any reason not specified in 
     paragraph (1), an individual breaches a written contract by 
     failing to either begin such individual's service obligation 
     required under such contract or to complete such service 
     obligation, the United States shall be entitled to recover 
     from the individual an amount determined in accordance with 
     the formula specified in subsection (l) of section 110 in the 
     manner provided for in such subsection.
       ``(3) Cancellation upon death of recipient.--Upon the death 
     of an individual who receives an Indian Health Scholarship, 
     any outstanding obligation of that individual for service or 
     payment that relates to that scholarship shall be canceled.
       ``(4) Information.--The Secretary may carry out this 
     subsection on the basis of information received from Tribal 
     Health Programs involved or on the basis of information 
     collected through such other means as the Secretary deems 
     appropriate.
       ``(f) Relation to Social Security Act.--The recipient of a 
     scholarship under this section shall agree, in providing 
     health care pursuant to the requirements herein--
       ``(1) not to discriminate against an individual seeking 
     care on the basis of the ability of the individual to pay for 
     such care or on the basis that payment for such care will be 
     made pursuant to a program established in title XVIII of the 
     Social Security Act or pursuant to the programs established 
     in title XIX or title XXI of such Act; and
       ``(2) to accept assignment under section 1842(b)(3)(B)(ii) 
     of the Social Security Act for all services for which payment 
     may be made under part B of title XVIII of such Act, and to 
     enter into an appropriate agreement with the State agency 
     that administers the State plan for medical assistance under 
     title XIX, or the State child health plan under title XXI, of 
     such Act to provide service to individuals entitled to 
     medical assistance or child health assistance, respectively, 
     under the plan.
       ``(g) Continuance of Funding.--The Secretary shall make 
     payments under this section to a Tribal Health Program for 
     any fiscal year subsequent to the first fiscal year of such 
     payments unless the Secretary determines that, for the 
     immediately preceding fiscal year, the Tribal Health Program 
     has not complied with the requirements of this section.

     ``SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

       ``(a) Employment Preference.--Any individual who receives a 
     scholarship pursuant to section 104 or 106 shall be given 
     preference for employment in the Service, or may be employed 
     by a Tribal Health Program or an urban Indian organization, 
     or other agencies of the Department as available, during any 
     nonacademic period of the year.
       ``(b) Not Counted Toward Active Duty Service Obligation.--
     Periods of employment pursuant to this subsection shall not 
     be counted in determining fulfillment of the service 
     obligation incurred as a condition of the scholarship.
       ``(c) Timing; Length of Employment.--Any individual 
     enrolled in a program, including a high school program, 
     authorized under section 102(a) may be employed by the 
     Service or by a Tribal Health Program or an urban Indian 
     organization during any nonacademic period of the year. Any 
     such employment shall not exceed 120 days during any calendar 
     year.
       ``(d) Nonapplicability of Competitive Personnel System.--
     Any employment pursuant to this section shall be made without 
     regard to any competitive personnel system or agency 
     personnel limitation and to a position which will enable the 
     individual so employed to receive practical experience in the 
     health profession in which he or she is engaged in study. Any 
     individual so employed shall receive payment for his or her 
     services comparable to the salary he or she would receive if 
     he or she were employed in the competitive system. Any 
     individual so employed shall not be counted against any 
     employment ceiling affecting the Service or the Department.

     ``SEC. 108. CONTINUING EDUCATION ALLOWANCES.

       ``In order to encourage scholarship and stipend recipients 
     under sections 104, 105, 106, and 115 and health 
     professionals, including community health representatives and 
     emergency medical technicians, to join or continue in an 
     Indian Health Program and to provide their services in the 
     rural and remote areas where a significant portion of Indians 
     reside, the Secretary, acting through the Service, may--
       ``(1) provide programs or allowances to transition into an 
     Indian Health Program, including licensing, board or 
     certification examination assistance, and technical 
     assistance in fulfilling service obligations under sections 
     104, 105, 106, and 115; and
       ``(2) provide programs or allowances to health 
     professionals employed in an Indian Health Program to enable 
     them for a period of time each year prescribed by regulation 
     of the Secretary to take leave of their duty stations for 
     professional consultation, management, leadership, and 
     refresher training courses.

     ``SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

       ``(a) In General.--Under the authority of the Act of 
     November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act'), the Secretary, acting through the Service, 
     shall maintain a Community Health Representative Program 
     under which Indian Health Programs--
       ``(1) provide for the training of Indians as community 
     health representatives; and
       ``(2) use such community health representatives in the 
     provision of health care, health promotion, and disease 
     prevention services to Indian communities.
       ``(b) Duties.--The Community Health Representative Program 
     of the Service, shall--
       ``(1) provide a high standard of training for community 
     health representatives to ensure that the community health 
     representatives provide quality health care, health 
     promotion, and disease prevention services to the Indian 
     communities served by the Program;
       ``(2) in order to provide such training, develop and 
     maintain a curriculum that--
       ``(A) combines education in the theory of health care with 
     supervised practical experience in the provision of health 
     care; and
       ``(B) provides instruction and practical experience in 
     health promotion and disease prevention activities, with 
     appropriate consideration given to lifestyle factors that 
     have an impact on Indian health status, such as alcoholism, 
     family dysfunction, and poverty;
       ``(3) maintain a system which identifies the needs of 
     community health representatives for continuing education in 
     health care, health promotion, and disease prevention and 
     develop programs that meet the needs for continuing 
     education;
       ``(4) maintain a system that provides close supervision of 
     Community Health Representatives;
       ``(5) maintain a system under which the work of Community 
     Health Representatives is reviewed and evaluated; and
       ``(6) promote traditional health care practices of the 
     Indian Tribes served consistent with the Service standards 
     for the provision of health care, health promotion, and 
     disease prevention.

[[Page 27398]]



     ``SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

       ``(a) Establishment.--The Secretary, acting through the 
     Service, shall establish and administer a program to be known 
     as the Service Loan Repayment Program (hereinafter referred 
     to as the `Loan Repayment Program') in order to ensure an 
     adequate supply of trained health professionals necessary to 
     maintain accreditation of, and provide health care services 
     to Indians through, Indian Health Programs and urban Indian 
     organizations.
       ``(b) Eligible Individuals.--To be eligible to participate 
     in the Loan Repayment Program, an individual must--
       ``(1)(A) be enrolled--
       ``(i) in a course of study or program in an accredited 
     educational institution (as determined by the Secretary under 
     section 338B(b)(1)(c)(i) of the Public Health Service Act (42 
     U.S.C. 254l-1(b)(1)(c)(i))) and be scheduled to complete such 
     course of study in the same year such individual applies to 
     participate in such program; or
       ``(ii) in an approved graduate training program in a health 
     profession; or
       ``(B) have--
       ``(i) a degree in a health profession; and
       ``(ii) a license to practice a health profession;
       ``(2)(A) be eligible for, or hold, an appointment as a 
     commissioned officer in the Regular or Reserve Corps of the 
     Public Health Service;
       ``(B) meet the professional standards for civil service 
     employment in the Service; or
       ``(C) be employed in an Indian Health Program or urban 
     Indian organization without a service obligation; and
       ``(3) submit to the Secretary an application for a contract 
     described in subsection (e).
       ``(c) Application.--
       ``(1) Information to be included with forms.--In 
     disseminating application forms and contract forms to 
     individuals desiring to participate in the Loan Repayment 
     Program, the Secretary shall include with such forms a fair 
     summary of the rights and liabilities of an individual whose 
     application is approved (and whose contract is accepted) by 
     the Secretary, including in the summary a clear explanation 
     of the damages to which the United States is entitled under 
     subsection (l) in the case of the individual's breach of 
     contract. The Secretary shall provide such individuals with 
     sufficient information regarding the advantages and 
     disadvantages of service as a commissioned officer in the 
     Regular or Reserve Corps of the Public Health Service or a 
     civilian employee of the Service to enable the individual to 
     make a decision on an informed basis.
       ``(2) Clear language.--The application form, contract form, 
     and all other information furnished by the Secretary under 
     this section shall be written in a manner calculated to be 
     understood by the average individual applying to participate 
     in the Loan Repayment Program.
       ``(3) Timely availability of forms.--The Secretary shall 
     make such application forms, contract forms, and other 
     information available to individuals desiring to participate 
     in the Loan Repayment Program on a date sufficiently early to 
     ensure that such individuals have adequate time to carefully 
     review and evaluate such forms and information.
       ``(d) Priorities.--
       ``(1) List.--Consistent with subsection (j), the Secretary 
     shall annually--
       ``(A) identify the positions in each Indian Health Program 
     or urban Indian organization for which there is a need or a 
     vacancy; and
       ``(B) rank those positions in order of priority.
       ``(2) Approvals.--Consistent with the priority determined 
     under paragraph (1), the Secretary, in determining which 
     applications under the Loan Repayment Program to approve (and 
     which contracts to accept), shall--
       ``(A) give first priority to applications made by 
     individual Indians; and
       ``(B) after making determinations on all applications 
     submitted by individual Indians as required under 
     subparagraph (A), give priority to--
       ``(i) individuals recruited through the efforts of an 
     Indian Health Program or urban Indian organization; and
       ``(ii) other individuals based on the priority rankings 
     under paragraph (1).
       ``(e) Recipient Contracts.--
       ``(1) Contract required.--An individual becomes a 
     participant in the Loan Repayment Program only upon the 
     Secretary and the individual entering into a written contract 
     described in paragraph (2).
       ``(2) Contents of contract.--The written contract referred 
     to in this section between the Secretary and an individual 
     shall contain--
       ``(A) an agreement under which--
       ``(i) subject to subparagraph (C), the Secretary agrees--

       ``(I) to pay loans on behalf of the individual in 
     accordance with the provisions of this section; and
       ``(II) to accept (subject to the availability of 
     appropriated funds for carrying out this section) the 
     individual into the Service or place the individual with a 
     Tribal Health Program or urban Indian organization as 
     provided in clause (ii)(III); and

       ``(ii) subject to subparagraph (C), the individual agrees--

       ``(I) to accept loan payments on behalf of the individual;
       ``(II) in the case of an individual described in subsection 
     (b)(1)--

       ``(aa) to maintain enrollment in a course of study or 
     training described in subsection (b)(1)(A) until the 
     individual completes the course of study or training; and
       ``(bb) while enrolled in such course of study or training, 
     to maintain an acceptable level of academic standing (as 
     determined under regulations of the Secretary by the 
     educational institution offering such course of study or 
     training); and

       ``(III) to serve for a time period (in this section 
     referred to as the `period of obligated service') equal to 2 
     years or such longer period as the individual may agree to 
     serve in the full-time clinical practice of such individual's 
     profession in an Indian Health Program or urban Indian 
     organization to which the individual may be assigned by the 
     Secretary;

       ``(B) a provision permitting the Secretary to extend for 
     such longer additional periods, as the individual may agree 
     to, the period of obligated service agreed to by the 
     individual under subparagraph (A)(ii)(III);
       ``(C) a provision that any financial obligation of the 
     United States arising out of a contract entered into under 
     this section and any obligation of the individual which is 
     conditioned thereon is contingent upon funds being 
     appropriated for loan repayments under this section;
       ``(D) a statement of the damages to which the United States 
     is entitled under subsection (k) for the individual's breach 
     of the contract; and
       ``(E) such other statements of the rights and liabilities 
     of the Secretary and of the individual, not inconsistent with 
     this section.
       ``(f) Deadline for Decision on Application.--The Secretary 
     shall provide written notice to an individual within 21 days 
     on--
       ``(1) the Secretary's approving, under subsection (e)(1), 
     of the individual's participation in the Loan Repayment 
     Program, including extensions resulting in an aggregate 
     period of obligated service in excess of 4 years; or
       ``(2) the Secretary's disapproving an individual's 
     participation in such Program.
       ``(g) Payments.--
       ``(1) In general.--A loan repayment provided for an 
     individual under a written contract under the Loan Repayment 
     Program shall consist of payment, in accordance with 
     paragraph (2), on behalf of the individual of the principal, 
     interest, and related expenses on government and commercial 
     loans received by the individual regarding the undergraduate 
     or graduate education of the individual (or both), which 
     loans were made for--
       ``(A) tuition expenses;
       ``(B) all other reasonable educational expenses, including 
     fees, books, and laboratory expenses, incurred by the 
     individual; and
       ``(C) reasonable living expenses as determined by the 
     Secretary.
       ``(2) Amount.--For each year of obligated service that an 
     individual contracts to serve under subsection (e), the 
     Secretary may pay up to $35,000 or an amount equal to the 
     amount specified in section 338B(g)(2)(A) of the Public 
     Health Service Act, whichever is more, on behalf of the 
     individual for loans described in paragraph (1). In making a 
     determination of the amount to pay for a year of such service 
     by an individual, the Secretary shall consider the extent to 
     which each such determination--
       ``(A) affects the ability of the Secretary to maximize the 
     number of contracts that can be provided under the Loan 
     Repayment Program from the amounts appropriated for such 
     contracts;
       ``(B) provides an incentive to serve in Indian Health 
     Programs and urban Indian organizations with the greatest 
     shortages of health professionals; and
       ``(C) provides an incentive with respect to the health 
     professional involved remaining in an Indian Health Program 
     or urban Indian organization with such a health professional 
     shortage, and continuing to provide primary health services, 
     after the completion of the period of obligated service under 
     the Loan Repayment Program.
       ``(3) Timing.--Any arrangement made by the Secretary for 
     the making of loan repayments in accordance with this 
     subsection shall provide that any repayments for a year of 
     obligated service shall be made no later than the end of the 
     fiscal year in which the individual completes such year of 
     service.
       ``(4) Reimbursements for tax liability.--For the purpose of 
     providing reimbursements for tax liability resulting from a 
     payment under paragraph (2) on behalf of an individual, the 
     Secretary--
       ``(A) in addition to such payments, may make payments to 
     the individual in an amount equal to not less than 20 percent 
     and not more than 39 percent of the total amount of loan 
     repayments made for the taxable year involved; and
       ``(B) may make such additional payments as the Secretary 
     determines to be appropriate with respect to such purpose.
       ``(5) Payment schedule.--The Secretary may enter into an 
     agreement with the holder of any loan for which payments are 
     made

[[Page 27399]]

     under the Loan Repayment Program to establish a schedule for 
     the making of such payments.
       ``(h) Employment Ceiling.--Notwithstanding any other 
     provision of law, individuals who have entered into written 
     contracts with the Secretary under this section shall not be 
     counted against any employment ceiling affecting the 
     Department while those individuals are undergoing academic 
     training.
       ``(i) Recruitment.--The Secretary shall conduct recruiting 
     programs for the Loan Repayment Program and other manpower 
     programs of the Service at educational institutions training 
     health professionals or specialists identified in subsection 
     (a).
       ``(j) Applicability of Law.--Section 214 of the Public 
     Health Service Act (42 U.S.C. 215) shall not apply to 
     individuals during their period of obligated service under 
     the Loan Repayment Program.
       ``(k) Assignment of Individuals.--The Secretary, in 
     assigning individuals to serve in Indian Health Programs or 
     urban Indian organizations pursuant to contracts entered into 
     under this section, shall--
       ``(1) ensure that the staffing needs of Tribal Health 
     Programs and urban Indian organizations receive consideration 
     on an equal basis with programs that are administered 
     directly by the Service; and
       ``(2) give priority to assigning individuals to Indian 
     Health Programs and urban Indian organizations that have a 
     need for health professionals to provide health care services 
     as a result of individuals having breached contracts entered 
     into under this section.
       ``(l) Breach of Contract.--
       ``(1) Specific breaches.--An individual who has entered 
     into a written contract with the Secretary under this section 
     and has not received a waiver under subsection (m) shall be 
     liable, in lieu of any service obligation arising under such 
     contract, to the United States for the amount which has been 
     paid on such individual's behalf under the contract if that 
     individual--
       ``(A) is enrolled in the final year of a course of study 
     and--
       ``(i) fails to maintain an acceptable level of academic 
     standing in the educational institution in which he or she is 
     enrolled (such level determined by the educational 
     institution under regulations of the Secretary);
       ``(ii) voluntarily terminates such enrollment; or
       ``(iii) is dismissed from such educational institution 
     before completion of such course of study; or
       ``(B) is enrolled in a graduate training program and fails 
     to complete such training program.
       ``(2) Other breaches; formula for amount owed.--If, for any 
     reason not specified in paragraph (1), an individual breaches 
     his or her written contract under this section by failing 
     either to begin, or complete, such individual's period of 
     obligated service in accordance with subsection (e)(2), the 
     United States shall be entitled to recover from such 
     individual an amount to be determined in accordance with the 
     following formula: A=3Z(t-s/t) in which--
       ``(A) `A' is the amount the United States is entitled to 
     recover;
       ``(B) `Z' is the sum of the amounts paid under this section 
     to, or on behalf of, the individual and the interest on such 
     amounts which would be payable if, at the time the amounts 
     were paid, they were loans bearing interest at the maximum 
     legal prevailing rate, as determined by the Secretary of the 
     Treasury;
       ``(C) `t' is the total number of months in the individual's 
     period of obligated service; and
       ``(D) `s' is the number of months of such period served by 
     such individual in accordance with this section.
       ``(3) Time period for repayment.--Any amount of damages 
     which the United States is entitled to recover under this 
     subsection shall be paid to the United States within the 1-
     year period beginning on the date of the breach or such 
     longer period beginning on such date as shall be specified by 
     the Secretary.
       ``(4) Deductions in medicare payments.--Amounts not paid 
     within such period shall be subject to collection through 
     deductions in Medicare payments pursuant to section 1892 of 
     the Social Security Act.
       ``(5) Recovery of delinquency.--
       ``(A) In general.--If damages described in paragraph (4) 
     are delinquent for 3 months, the Secretary shall, for the 
     purpose of recovering such damages--
       ``(i) use collection agencies contracted with by the 
     Administrator of General Services; or
       ``(ii) enter into contracts for the recovery of such 
     damages with collection agencies selected by the Secretary.
       ``(B) Report.--Each contract for recovering damages 
     pursuant to this subsection shall provide that the contractor 
     will, not less than once each 6 months, submit to the 
     Secretary a status report on the success of the contractor in 
     collecting such damages. Section 3718 of title 31, United 
     States Code, shall apply to any such contract to the extent 
     not inconsistent with this subsection.
       ``(m) Waiver or Suspension of Obligation.--
       ``(1) In general.--The Secretary shall by regulation 
     provide for the partial or total waiver or suspension of any 
     obligation of service or payment by an individual under the 
     Loan Repayment Program whenever compliance by the individual 
     is impossible or would involve extreme hardship to the 
     individual and if enforcement of such obligation with respect 
     to any individual would be unconscionable.
       ``(2) Canceled upon death.--Any obligation of an individual 
     under the Loan Repayment Program for service or payment of 
     damages shall be canceled upon the death of the individual.
       ``(3) Hardship waiver.--The Secretary may waive, in whole 
     or in part, the rights of the United States to recover 
     amounts under this section in any case of extreme hardship or 
     other good cause shown, as determined by the Secretary.
       ``(4) Bankruptcy.--Any obligation of an individual under 
     the Loan Repayment Program for payment of damages may be 
     released by a discharge in bankruptcy under title 11 of the 
     United States Code only if such discharge is granted after 
     the expiration of the 5-year period beginning on the first 
     date that payment of such damages is required, and only if 
     the bankruptcy court finds that nondischarge of the 
     obligation would be unconscionable.
       ``(n) Report.--The Secretary shall submit to the President, 
     for inclusion in the report required to be submitted to 
     Congress under section 801, a report concerning the previous 
     fiscal year which sets forth by Service Area the following:
       ``(1) A list of the health professional positions 
     maintained by Indian Health Programs and urban Indian 
     organizations for which recruitment or retention is 
     difficult.
       ``(2) The number of Loan Repayment Program applications 
     filed with respect to each type of health profession.
       ``(3) The number of contracts described in subsection (e) 
     that are entered into with respect to each health profession.
       ``(4) The amount of loan payments made under this section, 
     in total and by health profession.
       ``(5) The number of scholarships that are provided under 
     sections 104 and 106 with respect to each health profession.
       ``(6) The amount of scholarship grants provided under 
     sections 104 and 106, in total and by health profession.
       ``(7) The number of providers of health care that will be 
     needed by Indian Health Programs and urban Indian 
     organizations, by location and profession, during the 3 
     fiscal years beginning after the date the report is filed.
       ``(8) The measures the Secretary plans to take to fill the 
     health professional positions maintained by Indian Health 
     Programs or urban Indian organizations for which recruitment 
     or retention is difficult.

     ``SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

       ``(a) Establishment.--There is established in the Treasury 
     of the United States a fund to be known as the Indian Health 
     Scholarship and Loan Repayment Recovery Fund (hereafter in 
     this section referred to as the `LRRF'). The LRRF shall 
     consist of such amounts as may be collected from individuals 
     under section 104(d), section 106(e), and section 110(l) for 
     breach of contract, such funds as may be appropriated to the 
     LRRF, and interest earned on amounts in the LRRF. All amounts 
     collected, appropriated, or earned relative to the LRRF shall 
     remain available until expended.
       ``(b) Use of Funds.--
       ``(1) By secretary.--Amounts in the LRRF may be expended by 
     the Secretary, acting through the Service, to make payments 
     to an Indian Health Program--
       ``(A) to which a scholarship recipient under section 104 
     and 106 or a loan repayment program participant under section 
     110 has been assigned to meet the obligated service 
     requirements pursuant to such sections; and
       ``(B) that has a need for a health professional to provide 
     health care services as a result of such recipient or 
     participant having breached the contract entered into under 
     section 104, 106, or 110.
       ``(2) By tribal health programs.--A Tribal Health Program 
     receiving payments pursuant to paragraph (1) may expend the 
     payments to provide scholarships or recruit and employ, 
     directly or by contract, health professionals to provide 
     health care services.
       ``(c) Investment of Funds.--The Secretary of the Treasury 
     shall invest such amounts of the LRRF as the Secretary of 
     Health and Human Services determines are not required to meet 
     current withdrawals from the LRRF. Such investments may be 
     made only in interest bearing obligations of the United 
     States. For such purpose, such obligations may be acquired on 
     original issue at the issue price, or by purchase of 
     outstanding obligations at the market price.
       ``(d) Sale of Obligations.--Any obligation acquired by the 
     LRRF may be sold by the Secretary of the Treasury at the 
     market price.

     ``SEC. 112. RECRUITMENT ACTIVITIES.

       ``(a) Reimbursement for Travel.--The Secretary, acting 
     through the Service, may reimburse health professionals 
     seeking positions with Indian Health Programs or urban Indian 
     organizations, including individuals

[[Page 27400]]

     considering entering into a contract under section 110 and 
     their spouses, for actual and reasonable expenses incurred in 
     traveling to and from their places of residence to an area in 
     which they may be assigned for the purpose of evaluating such 
     area with respect to such assignment.
       ``(b) Recruitment Personnel.--The Secretary, acting through 
     the Service, shall assign 1 individual in each Area Office to 
     be responsible on a full-time basis for recruitment 
     activities.

     ``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

       ``(a) In General.--The Secretary, acting through the 
     Service, shall fund, on a competitive basis, innovative 
     demonstration projects for a period not to exceed 3 years to 
     enable Indian Health Programs and urban Indian organizations 
     to recruit, place, and retain health professionals to meet 
     their staffing needs.
       ``(b) Eligible Entities; Application.--Any Indian Health 
     Program or Urban Indian organization may submit an 
     application for funding of a project pursuant to this 
     section.

     ``SEC. 114. ADVANCED TRAINING AND RESEARCH.

       ``(a) Demonstration Program.--The Secretary, acting through 
     the Service, shall establish a demonstration project to 
     enable health professionals who have worked in an Indian 
     Health Program or urban Indian organization for a substantial 
     period of time to pursue advanced training or research areas 
     of study for which the Secretary determines a need exists.
       ``(b) Service Obligation.--An individual who participates 
     in a program under subsection (a), where the educational 
     costs are borne by the Service, shall incur an obligation to 
     serve in an Indian Health Program or urban Indian 
     organization for a period of obligated service equal to at 
     least the period of time during which the individual 
     participates in such program. In the event that the 
     individual fails to complete such obligated service, the 
     individual shall be liable to the United States for the 
     period of service remaining. In such event, with respect to 
     individuals entering the program after the date of enactment 
     of the Indian Health Care Improvement Act Amendments of 2009, 
     the United States shall be entitled to recover from such 
     individual an amount to be determined in accordance with the 
     formula specified in subsection (l) of section 110 in the 
     manner provided for in such subsection.
       ``(c) Equal Opportunity for Participation.--Health 
     professionals from Tribal Health Programs and urban Indian 
     organizations shall be given an equal opportunity to 
     participate in the program under subsection (a).

     ``SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING 
                   PROGRAM.

       ``(a) Grants Authorized.--For the purpose of increasing the 
     number of nurses, nurse midwives, and nurse practitioners who 
     deliver health care services to Indians, the Secretary, 
     acting through the Service, shall provide grants to the 
     following:
       ``(1) Public or private schools of nursing.
       ``(2) Tribal colleges or universities.
       ``(3) Nurse midwife programs and advanced practice nurse 
     programs that are provided by any tribal college or 
     university accredited nursing program, or in the absence of 
     such, any other public or private institutions.
       ``(b) Use of Grants.--Grants provided under subsection (a) 
     may be used for 1 or more of the following:
       ``(1) To recruit individuals for programs which train 
     individuals to be nurses, nurse midwives, or advanced 
     practice nurses.
       ``(2) To provide scholarships to Indians enrolled in such 
     programs that may pay the tuition charged for such program 
     and other expenses incurred in connection with such program, 
     including books, fees, room and board, and stipends for 
     living expenses.
       ``(3) To provide a program that encourages nurses, nurse 
     midwives, and advanced practice nurses to provide, or 
     continue to provide, health care services to Indians.
       ``(4) To provide a program that increases the skills of, 
     and provides continuing education to, nurses, nurse midwives, 
     and advanced practice nurses.
       ``(5) To provide any program that is designed to achieve 
     the purpose described in subsection (a).
       ``(c) Applications.--Each application for a grant under 
     subsection (a) shall include such information as the 
     Secretary may require to establish the connection between the 
     program of the applicant and a health care facility that 
     primarily serves Indians.
       ``(d) Preferences for Grant Recipients.--In providing 
     grants under subsection (a), the Secretary shall extend a 
     preference to the following:
       ``(1) Programs that provide a preference to Indians.
       ``(2) Programs that train nurse midwives or advanced 
     practice nurses.
       ``(3) Programs that are interdisciplinary.
       ``(4) Programs that are conducted in cooperation with a 
     program for gifted and talented Indian students.
       ``(5) Programs conducted by tribal colleges and 
     universities.
       ``(e) Quentin N. Burdick Program Grant.--The Secretary 
     shall provide 1 of the grants authorized under subsection (a) 
     to establish and maintain a program at the University of 
     North Dakota to be known as the `Quentin N. Burdick American 
     Indians Into Nursing Program'. Such program shall, to the 
     maximum extent feasible, coordinate with the Quentin N. 
     Burdick Indian Health Programs established under section 
     117(b) and the Quentin N. Burdick American Indians Into 
     Psychology Program established under section 105(b).
       ``(f) Active Duty Service Obligation.--The active duty 
     service obligation prescribed under section 338C of the 
     Public Health Service Act (42 U.S.C. 254m) shall be met by 
     each individual who receives training or assistance described 
     in paragraph (1) or (2) of subsection (b) that is funded by a 
     grant provided under subsection (a). Such obligation shall be 
     met by service--
       ``(1) in the Service;
       ``(2) in a program of an Indian Tribe or Tribal 
     Organization conducted under the Indian Self-Determination 
     and Education Assistance Act (25 U.S.C. 450 et seq.) 
     (including programs under agreements with the Bureau of 
     Indian Affairs);
       ``(3) in a program assisted under title V of this Act;
       ``(4) in the private practice of nursing if, as determined 
     by the Secretary, in accordance with guidelines promulgated 
     by the Secretary, such practice is situated in a physician or 
     other health shortage area and addresses the health care 
     needs of a substantial number of Indians; or
       ``(5) in a teaching capacity in a tribal college or 
     university nursing program (or a related health profession 
     program) if, as determined by the Secretary, health services 
     provided to Indians would not decrease.

     ``SEC. 116. TRIBAL CULTURAL ORIENTATION.

       ``(a) Cultural Education of Employees.--The Secretary, 
     acting through the Service, shall require that appropriate 
     employees of the Service who serve Indian Tribes in each 
     Service Area receive educational instruction in the history 
     and culture of such Indian Tribes and their relationship to 
     the Service.
       ``(b) Program.--In carrying out subsection (a), the 
     Secretary shall establish a program which shall, to the 
     extent feasible--
       ``(1) be developed in consultation with the affected Indian 
     Tribes, Tribal Organizations, and urban Indian organizations;
       ``(2) be carried out through tribal colleges or 
     universities;
       ``(3) include instruction in American Indian studies; and
       ``(4) describe the use and place of traditional health care 
     practices of the Indian Tribes in the Service Area.

     ``SEC. 117. INMED PROGRAM.

       ``(a) Grants Authorized.--The Secretary, acting through the 
     Service, is authorized to provide grants to colleges and 
     universities for the purpose of maintaining and expanding the 
     Indian health careers recruitment program known as the 
     `Indians Into Medicine Program' (hereinafter in this section 
     referred to as `INMED') as a means of encouraging Indians to 
     enter the health professions.
       ``(b) Quentin N. Burdick Grant.--The Secretary shall 
     provide 1 of the grants authorized under subsection (a) to 
     maintain the INMED program at the University of North Dakota, 
     to be known as the `Quentin N. Burdick Indian Health 
     Programs', unless the Secretary makes a determination, based 
     upon program reviews, that the program is not meeting the 
     purposes of this section. Such program shall, to the maximum 
     extent feasible, coordinate with the Quentin N. Burdick 
     American Indians Into Psychology Program established under 
     section 105(b) and the Quentin N. Burdick American Indians 
     Into Nursing Program established under section 115.
       ``(c) Regulations.--The Secretary, pursuant to this Act, 
     shall develop regulations to govern grants pursuant to this 
     section.
       ``(d) Requirements.--Applicants for grants provided under 
     this section shall agree to provide a program which--
       ``(1) provides outreach and recruitment for health 
     professions to Indian communities including elementary and 
     secondary schools and community colleges located on 
     reservations which will be served by the program;
       ``(2) incorporates a program advisory board comprised of 
     representatives from the Indian Tribes and Indian communities 
     which will be served by the program;
       ``(3) provides summer preparatory programs for Indian 
     students who need enrichment in the subjects of math and 
     science in order to pursue training in the health 
     professions;
       ``(4) provides tutoring, counseling, and support to 
     students who are enrolled in a health career program of study 
     at the respective college or university; and
       ``(5) to the maximum extent feasible, employs qualified 
     Indians in the program.

     ``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

       ``(a) Grants To Establish Programs.--
       ``(1) In general.--The Secretary, acting through the 
     Service, shall award grants to accredited and accessible 
     community colleges for the purpose of assisting such 
     community colleges in the establishment of programs which 
     provide education in a health profession leading to a degree 
     or diploma in a health profession for individuals who desire 
     to practice such profession on or near a reservation or in an 
     Indian Health Program.
       ``(2) Amount of grants.--The amount of any grant awarded to 
     a community college

[[Page 27401]]

     under paragraph (1) for the first year in which such a grant 
     is provided to the community college shall not exceed 
     $250,000.
       ``(b) Grants for Maintenance and Recruiting.--
       ``(1) In general.--The Secretary, acting through the 
     Service, shall award grants to accredited and accessible 
     community colleges that have established a program described 
     in subsection (a)(1) for the purpose of maintaining the 
     program and recruiting students for the program.
       ``(2) Requirements.--Grants may only be made under this 
     section to a community college which--
       ``(A) is accredited;
       ``(B) has a relationship with a hospital facility, Service 
     facility, or hospital that could provide training of nurses 
     or health professionals;
       ``(C) has entered into an agreement with an accredited 
     college or university medical school, the terms of which--
       ``(i) provide a program that enhances the transition and 
     recruitment of students into advanced baccalaureate or 
     graduate programs that train health professionals; and
       ``(ii) stipulate certifications necessary to approve 
     internship and field placement opportunities at Indian Health 
     Programs;
       ``(D) has a qualified staff which has the appropriate 
     certifications;
       ``(E) is capable of obtaining State or regional 
     accreditation of the program described in subsection (a)(1); 
     and
       ``(F) agrees to provide for Indian preference for 
     applicants for programs under this section.
       ``(c) Technical Assistance.--The Secretary shall encourage 
     community colleges described in subsection (b)(2) to 
     establish and maintain programs described in subsection 
     (a)(1) by--
       ``(1) entering into agreements with such colleges for the 
     provision of qualified personnel of the Service to teach 
     courses of study in such programs; and
       ``(2) providing technical assistance and support to such 
     colleges.
       ``(d) Advanced Training.--
       ``(1) Required.--Any program receiving assistance under 
     this section that is conducted with respect to a health 
     profession shall also offer courses of study which provide 
     advanced training for any health professional who--
       ``(A) has already received a degree or diploma in such 
     health profession; and
       ``(B) provides clinical services on or near a reservation 
     or for an Indian Health Program.
       ``(2) May be offered at alternate site.--Such courses of 
     study may be offered in conjunction with the college or 
     university with which the community college has entered into 
     the agreement required under subsection (b)(2)(C).
       ``(e) Priority.--Where the requirements of subsection (b) 
     are met, grant award priority shall be provided to tribal 
     colleges and universities in Service Areas where they exist.

     ``SEC. 119. RETENTION BONUS.

       ``(a) Bonus Authorized.--The Secretary may pay a retention 
     bonus to any health professional employed by, or assigned to, 
     and serving in, an Indian Health Program or urban Indian 
     organization either as a civilian employee or as a 
     commissioned officer in the Regular or Reserve Corps of the 
     Public Health Service who--
       ``(1) is assigned to, and serving in, a position for which 
     recruitment or retention of personnel is difficult;
       ``(2) the Secretary determines is needed by Indian Health 
     Programs and urban Indian organizations;
       ``(3) has--
       ``(A) completed 2 years of employment with an Indian Health 
     Program or urban Indian organization; or
       ``(B) completed any service obligations incurred as a 
     requirement of--
       ``(i) any Federal scholarship program; or
       ``(ii) any Federal education loan repayment program; and
       ``(4) enters into an agreement with an Indian Health 
     Program or urban Indian organization for continued employment 
     for a period of not less than 1 year.
       ``(b) Rates.--The Secretary may establish rates for the 
     retention bonus which shall provide for a higher annual rate 
     for multiyear agreements than for single year agreements 
     referred to in subsection (a)(4), but in no event shall the 
     annual rate be more than $25,000 per annum.
       ``(c) Default of Retention Agreement.--Any health 
     professional failing to complete the agreed upon term of 
     service, except where such failure is through no fault of the 
     individual, shall be obligated to refund to the Government 
     the full amount of the retention bonus for the period covered 
     by the agreement, plus interest as determined by the 
     Secretary in accordance with section 110(l)(2)(B).
       ``(d) Other Retention Bonus.--The Secretary may pay a 
     retention bonus to any health professional employed by a 
     Tribal Health Program if such health professional is serving 
     in a position which the Secretary determines is--
       ``(1) a position for which recruitment or retention is 
     difficult; and
       ``(2) necessary for providing health care services to 
     Indians.

     ``SEC. 120. NURSING RESIDENCY PROGRAM.

       ``(a) Establishment of Program.--The Secretary, acting 
     through the Service, shall establish a program to enable 
     Indians who are licensed practical nurses, licensed 
     vocational nurses, and registered nurses who are working in 
     an Indian Health Program or urban Indian organization, and 
     have done so for a period of not less than 1 year, to pursue 
     advanced training. Such program shall include a combination 
     of education and work study in an Indian Health Program or 
     urban Indian organization leading to an associate or 
     bachelor's degree (in the case of a licensed practical nurse 
     or licensed vocational nurse), a bachelor's degree (in the 
     case of a registered nurse), or advanced degrees or 
     certifications in nursing and public health.
       ``(b) Service Obligation.--An individual who participates 
     in a program under subsection (a), where the educational 
     costs are paid by the Service, shall incur an obligation to 
     serve in an Indian Health Program or urban Indian 
     organization for a period of obligated service equal to 1 
     year for every year that nonprofessional employee (licensed 
     practical nurses, licensed vocational nurses, nursing 
     assistants, and various health care technicians), or 2 years 
     for every year that professional nurse (associate degree and 
     bachelor-prepared registered nurses), participates in such 
     program. In the event that the individual fails to complete 
     such obligated service, the United States shall be entitled 
     to recover from such individual an amount determined in 
     accordance with the formula specified subsection (d)(1) of 
     Section 104 for individuals failing to graduate from their 
     degree program and subsection (l) of Section 110 for 
     individuals failing to start or complete the obligated 
     service.

     ``SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.

       ``(a) General Purposes of Program.--Under the authority of 
     the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as 
     the `Snyder Act'), the Secretary, acting through the Service, 
     shall develop and operate a Community Health Aide Program in 
     Alaska under which the Service--
       ``(1) provides for the training of Alaska Natives as health 
     aides or community health practitioners;
       ``(2) uses such aides or practitioners in the provision of 
     health care, health promotion, and disease prevention 
     services to Alaska Natives living in villages in rural 
     Alaska; and
       ``(3) provides for the establishment of teleconferencing 
     capacity in health clinics located in or near such villages 
     for use by community health aides or community health 
     practitioners.
       ``(b) Specific Program Requirements.--The Secretary, acting 
     through the Community Health Aide Program of the Service, 
     shall--
       ``(1) using trainers accredited by the Program, provide a 
     high standard of training to community health aides and 
     community health practitioners to ensure that such aides and 
     practitioners provide quality health care, health promotion, 
     and disease prevention services to the villages served by the 
     Program;
       ``(2) in order to provide such training, develop a 
     curriculum that--
       ``(A) combines education in the theory of health care with 
     supervised practical experience in the provision of health 
     care;
       ``(B) provides instruction and practical experience in the 
     provision of acute care, emergency care, health promotion, 
     disease prevention, and the efficient and effective 
     management of clinic pharmacies, supplies, equipment, and 
     facilities; and
       ``(C) promotes the achievement of the health status 
     objectives specified in section 3(2);
       ``(3) establish and maintain a Community Health Aide 
     Certification Board to certify as community health aides or 
     community health practitioners individuals who have 
     successfully completed the training described in paragraph 
     (1) or can demonstrate equivalent experience;
       ``(4) develop and maintain a system which identifies the 
     needs of community health aides and community health 
     practitioners for continuing education in the provision of 
     health care, including the areas described in paragraph 
     (2)(B), and develop programs that meet the needs for such 
     continuing education;
       ``(5) develop and maintain a system that provides close 
     supervision of community health aides and community health 
     practitioners;
       ``(6) develop a system under which the work of community 
     health aides and community health practitioners is reviewed 
     and evaluated to assure the provision of quality health care, 
     health promotion, and disease prevention services; and
       ``(7) ensure that pulpal therapy (not including pulpotomies 
     on deciduous teeth) or extraction of adult teeth can be 
     performed by a dental health aide therapist only after 
     consultation with a licensed dentist who determines that the 
     procedure is a medical emergency that cannot be resolved with 
     palliative treatment, and further that dental health aide 
     therapists are strictly prohibited from performing all other 
     oral or jaw surgeries, provided that uncomplicated 
     extractions shall not be considered oral surgery under this 
     section.
       ``(c) Program Review.--
       ``(1) Neutral panel.--

[[Page 27402]]

       ``(A) Establishment.--The Secretary, acting through the 
     Service, shall establish a neutral panel to carry out the 
     study under paragraph (2).
       ``(B) Membership.--Members of the neutral panel shall be 
     appointed by the Secretary from among clinicians, economists, 
     community practitioners, oral epidemiologists, and Alaska 
     Natives.
       ``(2) Study.--
       ``(A) In general.--The neutral panel established under 
     paragraph (1) shall conduct a study of the dental health aide 
     therapist services provided by the Community Health Aide 
     Program under this section to ensure that the quality of care 
     provided through those services is adequate and appropriate.
       ``(B) Parameters of study.--The Secretary, in consultation 
     with interested parties, including professional dental 
     organizations, shall develop the parameters of the study.
       ``(C) Inclusions.--The study shall include a determination 
     by the neutral panel with respect to--
       ``(i) the ability of the dental health aide therapist 
     services under this section to address the dental care needs 
     of Alaska Natives;
       ``(ii) the quality of care provided through those services, 
     including any training, improvement, or additional oversight 
     required to improve the quality of care; and
       ``(iii) whether safer and less costly alternatives to the 
     dental health aide therapist services exist.
       ``(D) Consultation.--In carrying out the study under this 
     paragraph, the neutral panel shall consult with Alaska Tribal 
     Organizations with respect to the adequacy and accuracy of 
     the study.
       ``(3) Report.--The neutral panel shall submit to the 
     Secretary, the Committee on Indian Affairs of the Senate, and 
     the Committee on Natural Resources of the House of 
     Representatives a report describing the results of the study 
     under paragraph (2), including a description of--
       ``(A) any determination of the neutral panel under 
     paragraph (2)(C); and
       ``(B) any comments received from an Alaska Tribal 
     Organization under paragraph (2)(D).
       ``(d) Nationalization of Program.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     Secretary, acting through the Service, may establish a 
     national Community Health Aide Program in accordance with the 
     program under this section, as the Secretary determines to be 
     appropriate.
       ``(2) Exception.--The national Community Health Aide 
     Program under paragraph (1) shall not include dental health 
     aide therapist services.
       ``(3) Requirement.--In establishing a national program 
     under paragraph (1), the Secretary shall not reduce the 
     amount of funds provided for the Community Health Aide 
     Program described in subsections (a) and (b).

     ``SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

       ``The Secretary shall, by contract or otherwise, provide 
     training for individuals in the administration and planning 
     of Tribal Health Programs, with priority to Indians.

     ``SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 
                   DEMONSTRATION PROGRAMS.

       ``(a) Demonstration Programs Authorized.--The Secretary, 
     acting through the Service, may fund demonstration programs 
     for Tribal Health Programs to address the chronic shortages 
     of health professionals.
       ``(b) Purposes of Programs.--The purposes of demonstration 
     programs funded under subsection (a) shall be--
       ``(1) to provide direct clinical and practical experience 
     at a Service Unit to health profession students and residents 
     from medical schools;
       ``(2) to improve the quality of health care for Indians by 
     assuring access to qualified health care professionals; and
       ``(3) to provide academic and scholarly opportunities for 
     health professionals serving Indians by identifying all 
     academic and scholarly resources of the region.
       ``(c) Advisory Board.--The demonstration programs 
     established pursuant to subsection (a) shall incorporate a 
     program advisory board composed of representatives from the 
     Indian Tribes and Indian communities in the area which will 
     be served by the program.

     ``SEC. 124. NATIONAL HEALTH SERVICE CORPS.

       ``(a) No Reduction in Services.--The Secretary shall not--
       ``(1) remove a member of the National Health Service Corps 
     from an Indian Health Program or urban Indian organization; 
     or
       ``(2) withdraw funding used to support such member, unless 
     the Secretary, acting through the Service, has ensured that 
     the Indians receiving services from such member will 
     experience no reduction in services.
       ``(b) Treatment of Indian Health Programs.--At the request 
     of an Indian Health Program, the services of a member of the 
     National Health Service Corps assigned to an Indian Health 
     Program may be limited to the persons who are eligible for 
     services from such Program.

     ``SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA 
                   DEMONSTRATION PROGRAMS.

       ``(a) Contracts and Grants.--The Secretary, acting through 
     the Service, may enter into contracts with, or make grants 
     to, accredited tribal colleges and universities and eligible 
     accredited and accessible community colleges to establish 
     demonstration programs to develop educational curricula for 
     substance abuse counseling.
       ``(b) Use of Funds.--Funds provided under this section 
     shall be used only for developing and providing educational 
     curriculum for substance abuse counseling (including paying 
     salaries for instructors). Such curricula may be provided 
     through satellite campus programs.
       ``(c) Time Period of Assistance; Renewal.--A contract 
     entered into or a grant provided under this section shall be 
     for a period of 3 years. Such contract or grant may be 
     renewed for an additional 2-year period upon the approval of 
     the Secretary.
       ``(d) Criteria for Review and Approval of Applications.--
     Not later than 180 days after the date of enactment of the 
     Indian Health Care Improvement Act Amendments of 2009, the 
     Secretary, after consultation with Indian Tribes and 
     administrators of tribal colleges and universities and 
     eligible accredited and accessible community colleges, shall 
     develop and issue criteria for the review and approval of 
     applications for funding (including applications for renewals 
     of funding) under this section. Such criteria shall ensure 
     that demonstration programs established under this section 
     promote the development of the capacity of such entities to 
     educate substance abuse counselors.
       ``(e) Assistance.--The Secretary shall provide such 
     technical and other assistance as may be necessary to enable 
     grant recipients to comply with the provisions of this 
     section.
       ``(f) Report.--Each fiscal year, the Secretary shall submit 
     to the President, for inclusion in the report which is 
     required to be submitted under section 801 for that fiscal 
     year, a report on the findings and conclusions derived from 
     the demonstration programs conducted under this section 
     during that fiscal year.
       ``(g) Definition.--For the purposes of this section, the 
     term `educational curriculum' means 1 or more of the 
     following:
       ``(1) Classroom education.
       ``(2) Clinical work experience.
       ``(3) Continuing education workshops.

     ``SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY 
                   EDUCATION PROGRAMS.

       ``(a) Study; List.--The Secretary, acting through the 
     Service, and the Secretary of the Interior, in consultation 
     with Indian Tribes and Tribal Organizations, shall conduct a 
     study and compile a list of the types of staff positions 
     specified in subsection (b) whose qualifications include, or 
     should include, training in the identification, prevention, 
     education, referral, or treatment of mental illness, or 
     dysfunctional and self-destructive behavior.
       ``(b) Positions.--The positions referred to in subsection 
     (a) are--
       ``(1) staff positions within the Bureau of Indian Affairs, 
     including existing positions, in the fields of--
       ``(A) elementary and secondary education;
       ``(B) social services and family and child welfare;
       ``(C) law enforcement and judicial services; and
       ``(D) alcohol and substance abuse;
       ``(2) staff positions within the Service; and
       ``(3) staff positions similar to those identified in 
     paragraphs (1) and (2) established and maintained by Indian 
     Tribes, Tribal Organizations (without regard to the funding 
     source), and urban Indian organizations.
       ``(c) Training Criteria.--
       ``(1) In general.--The appropriate Secretary shall provide 
     training criteria appropriate to each type of position 
     identified in subsection (b)(1) and (b)(2) and ensure that 
     appropriate training has been, or shall be provided to any 
     individual in any such position. With respect to any such 
     individual in a position identified pursuant to subsection 
     (b)(3), the respective Secretaries shall provide appropriate 
     training to, or provide funds to, an Indian Tribe, Tribal 
     Organization, or urban Indian organization for training of 
     appropriate individuals. In the case of positions funded 
     under a contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.), the appropriate Secretary shall ensure that such 
     training costs are included in the contract or compact, as 
     the Secretary determines necessary.
       ``(2) Position specific training criteria.--Position 
     specific training criteria shall be culturally relevant to 
     Indians and Indian Tribes and shall ensure that appropriate 
     information regarding traditional health care practices is 
     provided.
       ``(d) Community Education on Mental Illness.--The Service 
     shall develop and implement, on request of an Indian Tribe, 
     Tribal Organization, or urban Indian organization, or assist 
     the Indian Tribe, Tribal Organization, or urban Indian 
     organization to develop and implement, a program of community 
     education on mental illness. In carrying out this subsection, 
     the Service shall, upon request of an Indian Tribe, Tribal 
     Organization, or urban Indian organization, provide technical 
     assistance to the Indian Tribe, Tribal Organization, or urban 
     Indian organization to obtain and develop community 
     educational materials on the identification, prevention, 
     referral, and treatment of mental

[[Page 27403]]

     illness and dysfunctional and self-destructive behavior.
       ``(e) Plan.--Not later than 90 days after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary shall develop a plan under 
     which the Service will increase the health care staff 
     providing behavioral health services by at least 500 
     positions within 5 years after the date of enactment of this 
     section, with at least 200 of such positions devoted to 
     child, adolescent, and family services. The plan developed 
     under this subsection shall be implemented under the Act of 
     November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act').

     ``SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES.

       ``Employees of a Tribal Health Program or an Urban Indian 
     Organization shall be exempt from payment of licensing, 
     registration, and other fees imposed by a Federal agency to 
     the same extent that Commissioned Corps Officers or other 
     employees of the Indian Health Service are exempt from such 
     fees.

     ``SEC. 128. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated such sums as may 
     be necessary to carry out this title.

                      ``TITLE II--HEALTH SERVICES

     ``SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

       ``(a) Use of Funds.--The Secretary, acting through the 
     Service, is authorized to expend funds, directly or under the 
     authority of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.), which are 
     appropriated under the authority of this section, for the 
     purposes of--
       ``(1) eliminating the deficiencies in health status and 
     health resources of all Indian Tribes;
       ``(2) eliminating backlogs in the provision of health care 
     services to Indians;
       ``(3) meeting the health needs of Indians in an efficient 
     and equitable manner, including the use of telehealth and 
     telemedicine when appropriate;
       ``(4) eliminating inequities in funding for both direct 
     care and contract health service programs; and
       ``(5) augmenting the ability of the Service to meet the 
     following health service responsibilities with respect to 
     those Indian Tribes with the highest levels of health status 
     deficiencies and resource deficiencies:
       ``(A) Clinical care, including inpatient care, outpatient 
     care (including audiology, clinical eye, and vision care), 
     primary care, secondary and tertiary care, and long-term 
     care.
       ``(B) Preventive health, including mammography and other 
     cancer screening in accordance with section 207.
       ``(C) Dental care.
       ``(D) Mental health, including community mental health 
     services, inpatient mental health services, dormitory mental 
     health services, therapeutic and residential treatment 
     centers, and training of traditional health care 
     practitioners.
       ``(E) Emergency medical services.
       ``(F) Treatment and control of, and rehabilitative care 
     related to, alcoholism and drug abuse (including fetal 
     alcohol syndrome) among Indians.
       ``(G) Injury prevention programs, including data collection 
     and evaluation, demonstration projects, training, and 
     capacity building.
       ``(H) Home health care.
       ``(I) Community health representatives.
       ``(J) Maintenance and improvement.
       ``(b) No Offset or Limitation.--Any funds appropriated 
     under the authority of this section shall not be used to 
     offset or limit any other appropriations made to the Service 
     under this Act or the Act of November 2, 1921 (25 U.S.C. 13) 
     (commonly known as the `Snyder Act'), or any other provision 
     of law.
       ``(c) Allocation; Use.--
       ``(1) In general.--Funds appropriated under the authority 
     of this section shall be allocated to Service Units, Indian 
     Tribes, or Tribal Organizations. The funds allocated to each 
     Indian Tribe, Tribal Organization, or Service Unit under this 
     paragraph shall be used by the Indian Tribe, Tribal 
     Organization, or Service Unit under this paragraph to improve 
     the health status and reduce the resource deficiency of each 
     Indian Tribe served by such Service Unit, Indian Tribe, or 
     Tribal Organization.
       ``(2) Apportionment of allocated funds.--The apportionment 
     of funds allocated to a Service Unit, Indian Tribe, or Tribal 
     Organization under paragraph (1) among the health service 
     responsibilities described in subsection (a)(5) shall be 
     determined by the Service in consultation with, and with the 
     active participation of, the affected Indian Tribes and 
     Tribal Organizations.
       ``(d) Provisions Relating to Health Status and Resource 
     Deficiencies.--For the purposes of this section, the 
     following definitions apply:
       ``(1) Definition.--The term `health status and resource 
     deficiency' means the extent to which--
       ``(A) the health status objectives set forth in section 
     3(2) are not being achieved; and
       ``(B) the Indian Tribe or Tribal Organization does not have 
     available to it the health resources it needs, taking into 
     account the actual cost of providing health care services 
     given local geographic, climatic, rural, or other 
     circumstances.
       ``(2) Available resources.--The health resources available 
     to an Indian Tribe or Tribal Organization include health 
     resources provided by the Service as well as health resources 
     used by the Indian Tribe or Tribal Organization, including 
     services and financing systems provided by any Federal 
     programs, private insurance, and programs of State or local 
     governments.
       ``(3) Process for review of determinations.--The Secretary 
     shall establish procedures which allow any Indian Tribe or 
     Tribal Organization to petition the Secretary for a review of 
     any determination of the extent of the health status and 
     resource deficiency of such Indian Tribe or Tribal 
     Organization.
       ``(e) Eligibility for Funds.--Tribal Health Programs shall 
     be eligible for funds appropriated under the authority of 
     this section on an equal basis with programs that are 
     administered directly by the Service.
       ``(f) Report.--By no later than the date that is 3 years 
     after the date of enactment of the Indian Health Care 
     Improvement Act Amendments of 2009, the Secretary shall 
     submit to Congress the current health status and resource 
     deficiency report of the Service for each Service Unit, 
     including newly recognized or acknowledged Indian Tribes. 
     Such report shall set out--
       ``(1) the methodology then in use by the Service for 
     determining Tribal health status and resource deficiencies, 
     as well as the most recent application of that methodology;
       ``(2) the extent of the health status and resource 
     deficiency of each Indian Tribe served by the Service or a 
     Tribal Health Program;
       ``(3) the amount of funds necessary to eliminate the health 
     status and resource deficiencies of all Indian Tribes served 
     by the Service or a Tribal Health Program; and
       ``(4) an estimate of--
       ``(A) the amount of health service funds appropriated under 
     the authority of this Act, or any other Act, including the 
     amount of any funds transferred to the Service for the 
     preceding fiscal year which is allocated to each Service 
     Unit, Indian Tribe, or Tribal Organization;
       ``(B) the number of Indians eligible for health services in 
     each Service Unit or Indian Tribe or Tribal Organization; and
       ``(C) the number of Indians using the Service resources 
     made available to each Service Unit, Indian Tribe or Tribal 
     Organization, and, to the extent available, information on 
     the waiting lists and number of Indians turned away for 
     services due to lack of resources.
       ``(g) Inclusion in Base Budget.--Funds appropriated under 
     this section for any fiscal year shall be included in the 
     base budget of the Service for the purpose of determining 
     appropriations under this section in subsequent fiscal years.
       ``(h) Clarification.--Nothing in this section is intended 
     to diminish the primary responsibility of the Service to 
     eliminate existing backlogs in unmet health care needs, nor 
     are the provisions of this section intended to discourage the 
     Service from undertaking additional efforts to achieve equity 
     among Indian Tribes and Tribal Organizations.
       ``(i) Funding Designation.--Any funds appropriated under 
     the authority of this section shall be designated as the 
     `Indian Health Care Improvement Fund'.

     ``SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

       ``(a) Findings.--Congress finds that health promotion and 
     disease prevention activities--
       ``(1) improve the health and well-being of Indians; and
       ``(2) reduce the expenses for health care of Indians.
       ``(b) Provision of Services.--The Secretary, acting through 
     the Service, shall provide health promotion and disease 
     prevention services to Indians to achieve the health status 
     objectives set forth in section 3(2).
       ``(c) Evaluation.--The Secretary, after obtaining input 
     from the affected Tribal Health Programs, shall submit to the 
     President for inclusion in the report which is required to be 
     submitted to Congress under section 801 an evaluation of--
       ``(1) the health promotion and disease prevention needs of 
     Indians;
       ``(2) the health promotion and disease prevention 
     activities which would best meet such needs;
       ``(3) the internal capacity of the Service and Tribal 
     Health Programs to meet such needs; and
       ``(4) the resources which would be required to enable the 
     Service and Tribal Health Programs to undertake the health 
     promotion and disease prevention activities necessary to meet 
     such needs.

     ``SEC. 203. DIABETES PREVENTION, TREATMENT, AND CONTROL.

       ``(a) Determinations Regarding Diabetes.--The Secretary, 
     acting through the Service, and in consultation with Indian 
     Tribes and Tribal Organizations, shall determine--
       ``(1) by Indian Tribe and by Service Unit, the incidence 
     of, and the types of complications resulting from, diabetes 
     among Indians; and

[[Page 27404]]

       ``(2) based on the determinations made pursuant to 
     paragraph (1), the measures (including patient education and 
     effective ongoing monitoring of disease indicators) each 
     Service Unit should take to reduce the incidence of, and 
     prevent, treat, and control the complications resulting from, 
     diabetes among Indian Tribes within that Service Unit.
       ``(b) Diabetes Screening.--To the extent medically 
     indicated and with informed consent, the Secretary shall 
     screen each Indian who receives services from the Service for 
     diabetes and for conditions which indicate a high risk that 
     the individual will become diabetic and establish a cost-
     effective approach to ensure ongoing monitoring of disease 
     indicators. Such screening and monitoring may be conducted by 
     a Tribal Health Program and may be conducted through 
     appropriate Internet-based health care management programs.
       ``(c) Diabetes Projects.--The Secretary shall continue to 
     maintain each model diabetes project in existence on the date 
     of enactment of the Indian Health Care Improvement Act 
     Amendments of 2009.
       ``(d) Dialysis Programs.--The Secretary is authorized to 
     provide, through the Service, Indian Tribes, and Tribal 
     Organizations, dialysis programs, including the purchase of 
     dialysis equipment and the provision of necessary staffing.
       ``(e) Other Duties of the Secretary.--
       ``(1) In general.--The Secretary shall, to the extent 
     funding is available--
       ``(A) in each Area Office, consult with Indian Tribes and 
     Tribal Organizations regarding programs for the prevention, 
     treatment, and control of diabetes;
       ``(B) establish in each Area Office a registry of patients 
     with diabetes to track the incidence of diabetes and the 
     complications from diabetes in that area; and
       ``(C) ensure that data collected in each Area Office 
     regarding diabetes and related complications among Indians 
     are disseminated to all other Area Offices, subject to 
     applicable patient privacy laws.
       ``(2) Diabetes control officers.--
       ``(A) In general.--The Secretary may establish and maintain 
     in each Area Office a position of diabetes control officer to 
     coordinate and manage any activity of that Area Office 
     relating to the prevention, treatment, or control of diabetes 
     to assist the Secretary in carrying out a program under this 
     section or section 330C of the Public Health Service Act (42 
     U.S.C. 254c-3).
       ``(B) Certain activities.--Any activity carried out by a 
     diabetes control officer under subparagraph (A) that is the 
     subject of a contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.), and any funds made available to carry out such an 
     activity, shall not be divisible for purposes of that Act.

     ``SEC. 204. SHARED SERVICES FOR LONG-TERM CARE.

       ``(a) Long-term Care.--Notwithstanding any other provision 
     of law, the Secretary, acting through the Service, is 
     authorized to provide directly, or enter into contracts or 
     compacts under the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or 
     Tribal Organizations for, the delivery of long-term care 
     (including health care services associated with long-term 
     care) provided in a facility to Indians. Such agreements 
     shall provide for the sharing of staff or other services 
     between the Service or a Tribal Health Program and a long-
     term care or related facility owned and operated (directly or 
     through a contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.)) by such Indian Tribe or Tribal Organization.
       ``(b) Contents of Agreements.--An agreement entered into 
     pursuant to subsection (a)--
       ``(1) may, at the request of the Indian Tribe or Tribal 
     Organization, delegate to such Indian Tribe or Tribal 
     Organization such powers of supervision and control over 
     Service employees as the Secretary deems necessary to carry 
     out the purposes of this section;
       ``(2) shall provide that expenses (including salaries) 
     relating to services that are shared between the Service and 
     the Tribal Health Program be allocated proportionately 
     between the Service and the Indian Tribe or Tribal 
     Organization; and
       ``(3) may authorize such Indian Tribe or Tribal 
     Organization to construct, renovate, or expand a long-term 
     care or other similar facility (including the construction of 
     a facility attached to a Service facility).
       ``(c) Minimum Requirement.--Any nursing facility provided 
     for under this section shall meet the requirements for 
     nursing facilities under section 1919 of the Social Security 
     Act.
       ``(d) Other Assistance.--The Secretary shall provide such 
     technical and other assistance as may be necessary to enable 
     applicants to comply with the provisions of this section.
       ``(e) Use of Existing or Underused Facilities.--The 
     Secretary shall encourage the use of existing facilities that 
     are underused or allow the use of swing beds for long-term or 
     similar care.

     ``SEC. 205. HEALTH SERVICES RESEARCH.

       ``(a) In General.--The Secretary, acting through the 
     Service, shall make funding available for research to further 
     the performance of the health service responsibilities of 
     Indian Health Programs.
       ``(b) Coordination of Resources and Activities.--The 
     Secretary shall also, to the maximum extent practicable, 
     coordinate departmental research resources and activities to 
     address relevant Indian Health Program research needs.
       ``(c) Availability.--Tribal Health Programs shall be given 
     an equal opportunity to compete for, and receive, research 
     funds under this section.
       ``(d) Use of Funds.--This funding may be used for both 
     clinical and nonclinical research.
       ``(e) Evaluation and Dissemination.--The Secretary shall 
     periodically--
       ``(1) evaluate the impact of research conducted under this 
     section; and
       ``(2) disseminate to Tribal Health Programs information 
     regarding that research as the Secretary determines to be 
     appropriate.

     ``SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREENING.

       ``The Secretary, acting through the Service, shall provide 
     for screening as follows:
       ``(1) Screening mammography (as defined in section 1861(jj) 
     of the Social Security Act) for Indian women at a frequency 
     appropriate to such women under accepted and appropriate 
     national standards, and under such terms and conditions as 
     are consistent with standards established by the Secretary to 
     ensure the safety and accuracy of screening mammography under 
     part B of title XVIII of such Act.
       ``(2) Other cancer screening that receives an A or B rating 
     as recommended by the United States Preventive Services Task 
     Force established under section 915(a)(1) of the Public 
     Health Service Act (42 U.S.C. 299b-4(a)(1)). The Secretary 
     shall ensure that screening provided for under this paragraph 
     complies with the recommendations of the Task Force with 
     respect to--
       ``(A) frequency;
       ``(B) the population to be served;
       ``(C) the procedure or technology to be used;
       ``(D) evidence of effectiveness; and
       ``(E) other matters that the Secretary determines 
     appropriate.

     ``SEC. 207. PATIENT TRAVEL COSTS.

       ``(a) Definition of Qualified Escort.--In this section, the 
     term `qualified escort' means--
       ``(1) an adult escort (including a parent, guardian, or 
     other family member) who is required because of the physical 
     or mental condition, or age, of the applicable patient;
       ``(2) a health professional for the purpose of providing 
     necessary medical care during travel by the applicable 
     patient; or
       ``(3) other escorts, as the Secretary or applicable Indian 
     Health Program determines to be appropriate.
       ``(b) Provision of Funds.--The Secretary, acting through 
     the Service, is authorized to provide funds for the following 
     patient travel costs, including qualified escorts, associated 
     with receiving health care services provided (either through 
     direct or contract care or through a contract or compact 
     under the Indian Self-Determination and Education Assistance 
     Act (25 U.S.C. 450 et seq.)) under this Act--
       ``(1) emergency air transportation and non-emergency air 
     transportation where ground transportation is infeasible;
       ``(2) transportation by private vehicle (where no other 
     means of transportation is available), specially equipped 
     vehicle, and ambulance; and
       ``(3) transportation by such other means as may be 
     available and required when air or motor vehicle 
     transportation is not available.

     ``SEC. 208. EPIDEMIOLOGY CENTERS.

       ``(a) Establishment of Centers.--The Secretary shall 
     establish an epidemiology center in each Service Area to 
     carry out the functions described in subsection (b). Any new 
     center established after the date of enactment of the Indian 
     Health Care Improvement Act Amendments of 2008 may be 
     operated under a grant authorized by subsection (d), but 
     funding under such a grant shall not be divisible.
       ``(b) Functions of Centers.--In consultation with and upon 
     the request of Indian Tribes, Tribal Organizations, and Urban 
     Indian communities, each Service Area epidemiology center 
     established under this section shall, with respect to such 
     Service Area--
       ``(1) collect data relating to, and monitor progress made 
     toward meeting, each of the health status objectives of the 
     Service, the Indian Tribes, Tribal Organizations, and Urban 
     Indian communities in the Service Area;
       ``(2) evaluate existing delivery systems, data systems, and 
     other systems that impact the improvement of Indian health;
       ``(3) assist Indian Tribes, Tribal Organizations, and Urban 
     Indian Organizations in identifying their highest priority 
     health status objectives and the services needed to achieve 
     such objectives, based on epidemiological data;
       ``(4) make recommendations for the targeting of services 
     needed by the populations served;
       ``(5) make recommendations to improve health care delivery 
     systems for Indians and Urban Indians;

[[Page 27405]]

       ``(6) provide requested technical assistance to Indian 
     Tribes, Tribal Organizations, and Urban Indian Organizations 
     in the development of local health service priorities and 
     incidence and prevalence rates of disease and other illness 
     in the community; and
       ``(7) provide disease surveillance and assist Indian 
     Tribes, Tribal Organizations, and Urban Indian communities to 
     promote public health.
       ``(c) Technical Assistance.--The Director of the Centers 
     for Disease Control and Prevention shall provide technical 
     assistance to the centers in carrying out the requirements of 
     this section.
       ``(d) Grants for Studies.--
       ``(1) In general.--The Secretary may make grants to Indian 
     Tribes, Tribal Organizations, Indian organizations, and 
     eligible intertribal consortia to conduct epidemiological 
     studies of Indian communities.
       ``(2) Eligible intertribal consortia.--An intertribal 
     consortium or Indian organization is eligible to receive a 
     grant under this subsection if--
       ``(A) the intertribal consortium is incorporated for the 
     primary purpose of improving Indian health; and
       ``(B) the intertribal consortium is representative of the 
     Indian Tribes or urban Indian communities in which the 
     intertribal consortium is located.
       ``(3) Applications.--An application for a grant under this 
     subsection shall be submitted in such manner and at such time 
     as the Secretary shall prescribe.
       ``(4) Requirements.--An applicant for a grant under this 
     subsection shall--
       ``(A) demonstrate the technical, administrative, and 
     financial expertise necessary to carry out the functions 
     described in paragraph (5);
       ``(B) consult and cooperate with providers of related 
     health and social services in order to avoid duplication of 
     existing services; and
       ``(C) demonstrate cooperation from Indian Tribes or Urban 
     Indian Organizations in the area to be served.
       ``(5) Use of funds.--A grant awarded under paragraph (1) 
     may be used--
       ``(A) to carry out the functions described in subsection 
     (b);
       ``(B) to provide information to and consult with tribal 
     leaders, urban Indian community leaders, and related health 
     staff on health care and health service management issues; 
     and
       ``(C) in collaboration with Indian Tribes, Tribal 
     Organizations, and urban Indian communities, to provide the 
     Service with information regarding ways to improve the health 
     status of Indians.
       ``(e) Access to Information.--
       ``(1) An epidemiology center operated by a grantee pursuant 
     to a grant awarded under subsection (d) shall be treated as a 
     public health authority for purposes of the Health Insurance 
     Portability and Accountability Act of 1996, as such entities 
     are defined in part 164.501 of title 45, Code of Federal 
     Regulations.
       ``(2) The Secretary shall grant to such epidemiology center 
     access to use of the data, data sets, monitoring systems, 
     delivery systems, and other protected health information in 
     the possession of the Secretary.
       ``(3) The activities of such an epidemiology center shall 
     be for the purposes of research and for preventing and 
     controlling disease, injury, or disability for purposes of 
     the Health Insurance Portability and Accountability Act of 
     1996 (Public Law 104-191; 110 Stat. 2033), as such activities 
     are described in part 164.512 of title 45, Code of Federal 
     Regulations (or a successor regulation).
       ``(f) Funds Not Divisible.--An epidemiology center 
     established under this section shall be subject to the 
     provisions of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.), but the funds for 
     such center shall not be divisible.

     ``SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

       ``(a) Funding for Development of Programs.--In addition to 
     carrying out any other program for health promotion or 
     disease prevention, the Secretary, acting through the 
     Service, is authorized to award grants to Indian Tribes and 
     Tribal Organizations to develop comprehensive school health 
     education programs for children from pre-school through grade 
     12 in schools for the benefit of Indian children.
       ``(b) Use of Grant Funds.--A grant awarded under this 
     section may be used for purposes which may include, but are 
     not limited to, the following:
       ``(1) Developing health education materials both for 
     regular school programs and afterschool programs.
       ``(2) Training teachers in comprehensive school health 
     education materials.
       ``(3) Integrating school-based, community-based, and other 
     public and private health promotion efforts.
       ``(4) Encouraging healthy, tobacco-free school 
     environments.
       ``(5) Coordinating school-based health programs with 
     existing services and programs available in the community.
       ``(6) Developing school programs on nutrition education, 
     personal health, oral health, and fitness.
       ``(7) Developing behavioral health wellness programs.
       ``(8) Developing chronic disease prevention programs.
       ``(9) Developing substance abuse prevention programs.
       ``(10) Developing injury prevention and safety education 
     programs.
       ``(11) Developing activities for the prevention and control 
     of communicable diseases.
       ``(12) Developing community and environmental health 
     education programs that include traditional health care 
     practitioners.
       ``(13) Violence prevention.
       ``(14) Such other health issues as are appropriate.
       ``(c) Technical Assistance.--Upon request, the Secretary, 
     acting through the Service, shall provide technical 
     assistance to Indian Tribes and Tribal Organizations in the 
     development of comprehensive health education plans and the 
     dissemination of comprehensive health education materials and 
     information on existing health programs and resources.
       ``(d) Criteria for Review and Approval of Applications.--
     The Secretary, acting through the Service, and in 
     consultation with Indian Tribes and Tribal Organizations, 
     shall establish criteria for the review and approval of 
     applications for grants awarded under this section.
       ``(e) Development of Program for BIA-funded Schools.--
       ``(1) In general.--The Secretary of the Interior, acting 
     through the Bureau of Indian Affairs and in cooperation with 
     the Secretary, acting through the Service, shall develop a 
     comprehensive school health education program for children 
     from preschool through grade 12 in schools for which support 
     is provided by the Bureau of Indian Affairs.
       ``(2) Requirements for programs.--Such programs shall 
     include--
       ``(A) school programs on nutrition education, personal 
     health, oral health, and fitness;
       ``(B) behavioral health wellness programs;
       ``(C) chronic disease prevention programs;
       ``(D) substance abuse prevention programs;
       ``(E) injury prevention and safety education programs; and
       ``(F) activities for the prevention and control of 
     communicable diseases.
       ``(3) Duties of the secretary.--The Secretary of the 
     Interior shall--
       ``(A) provide training to teachers in comprehensive school 
     health education materials;
       ``(B) ensure the integration and coordination of school-
     based programs with existing services and health programs 
     available in the community; and
       ``(C) encourage healthy, tobacco-free school environments.

     ``SEC. 210. INDIAN YOUTH PROGRAM.

       ``(a) Program Authorized.--The Secretary, acting through 
     the Service, is authorized to establish and administer a 
     program to provide grants to Indian Tribes, Tribal 
     Organizations, and urban Indian organizations for innovative 
     mental and physical disease prevention and health promotion 
     and treatment programs for Indian and urban Indian 
     preadolescent and adolescent youths.
       ``(b) Use of Funds.--
       ``(1) Allowable uses.--Funds made available under this 
     section may be used to--
       ``(A) develop prevention and treatment programs for Indian 
     youth which promote mental and physical health and 
     incorporate cultural values, community and family 
     involvement, and traditional health care practitioners; and
       ``(B) develop and provide community training and education.
       ``(2) Prohibited use.--Funds made available under this 
     section may not be used to provide services described in 
     section 707(c).
       ``(c) Duties of the Secretary.--The Secretary shall--
       ``(1) disseminate to Indian Tribes, Tribal Organizations, 
     and urban Indian organizations information regarding models 
     for the delivery of comprehensive health care services to 
     Indian and urban Indian adolescents;
       ``(2) encourage the implementation of such models; and
       ``(3) at the request of an Indian Tribe, Tribal 
     Organization, or urban Indian organization, provide technical 
     assistance in the implementation of such models.
       ``(d) Criteria for Review and Approval of Applications.--
     The Secretary, in consultation with Indian Tribes, Tribal 
     Organizations, and urban Indian organizations, shall 
     establish criteria for the review and approval of 
     applications or proposals under this section.

     ``SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF 
                   COMMUNICABLE AND INFECTIOUS DISEASES.

       ``(a) Grants Authorized.--The Secretary, acting through the 
     Service, and after consultation with the Centers for Disease 
     Control and Prevention, may make grants available to Indian 
     Tribes, Tribal Organizations, and urban Indian organizations 
     for the following:
       ``(1) Projects for the prevention, control, and elimination 
     of communicable and infectious diseases, including 
     tuberculosis, hepatitis, HIV, respiratory syncytial virus, 
     hanta virus, sexually transmitted diseases, and H. Pylori.
       ``(2) Public information and education programs for the 
     prevention, control, and elimination of communicable and 
     infectious diseases.
       ``(3) Education, training, and clinical skills improvement 
     activities in the prevention,

[[Page 27406]]

     control, and elimination of communicable and infectious 
     diseases for health professionals, including allied health 
     professionals.
       ``(4) Demonstration projects for the screening, treatment, 
     and prevention of hepatitis C virus (HCV).
       ``(b) Application Required.--The Secretary may provide 
     funding under subsection (a) only if an application or 
     proposal for funding is submitted to the Secretary.
       ``(c) Coordination With Health Agencies.--Indian Tribes, 
     Tribal Organizations, and urban Indian organizations 
     receiving funding under this section are encouraged to 
     coordinate their activities with the Centers for Disease 
     Control and Prevention and State and local health agencies.
       ``(d) Technical Assistance; Report.--In carrying out this 
     section, the Secretary--
       ``(1) may, at the request of an Indian Tribe, Tribal 
     Organization, or urban Indian organization, provide technical 
     assistance; and
       ``(2) shall prepare and submit a report to Congress 
     biennially on the use of funds under this section and on the 
     progress made toward the prevention, control, and elimination 
     of communicable and infectious diseases among Indians and 
     Urban Indians.

     ``SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERVICES.

       ``(a) Funding Authorized.--The Secretary may provide 
     funding under this Act to meet the objectives set forth in 
     section 3 of this Act through health care-related services 
     and programs of the Service, Indian Tribes, and Tribal 
     Organizations not otherwise described in this Act for the 
     following services:
       ``(1) Hospice care.
       ``(2) Assisted living services.
       ``(3) Long-term care services.
       ``(4) Home- and community-based services.
       ``(b) Eligibility.--The following individuals shall be 
     eligible to receive long-term care under this section:
       ``(1) Individuals who are unable to perform a certain 
     number of activities of daily living without assistance.
       ``(2) Individuals with a mental impairment, such as 
     dementia, Alzheimer's disease, or another disabling mental 
     illness, who may be able to perform activities of daily 
     living under supervision.
       ``(3) Such other individuals as an applicable Indian Health 
     Program determines to be appropriate.
       ``(c) Definitions.--For the purposes of this section, the 
     following definitions shall apply:
       ``(1) The term `assisted living services' means any service 
     provided by an assisted living facility (as defined in 
     section 232(b) of the National Housing Act (12 U.S.C. 
     1715w(b))), except that such an assisted living facility--
       ``(A) shall not be required to obtain a license; but
       ``(B) shall meet all applicable standards for licensure.
       ``(2) The term `home- and community-based services' means 1 
     or more of the services specified in paragraphs (1) through 
     (9) of section 1929(a) of the Social Security Act (42 U.S.C. 
     1396t(a)) (whether provided by the Service or by an Indian 
     Tribe or Tribal Organization pursuant to the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.)) that are or will be provided in accordance with 
     applicable standards.
       ``(3) The term `hospice care' means the items and services 
     specified in subparagraphs (A) through (H) of section 
     1861(dd)(1) of the Social Security Act (42 U.S.C. 
     1395x(dd)(1)), and such other services which an Indian Tribe 
     or Tribal Organization determines are necessary and 
     appropriate to provide in furtherance of this care.
       ``(4) The term `long-term care services' has the meaning 
     given the term `qualified long-term care services' in section 
     7702B(c) of the Internal Revenue Code of 1986.
       ``(d) Authorization of Convenient Care Services.--The 
     Secretary, acting through the Service, Indian Tribes, and 
     Tribal Organizations, may also provide funding under this Act 
     to meet the objectives set forth in section 3 of this Act for 
     convenient care services programs pursuant to section 
     306(c)(2)(A).

     ``SEC. 213. INDIAN WOMEN'S HEALTH CARE.

       ``The Secretary, acting through the Service and Indian 
     Tribes, Tribal Organizations, and Urban Indian Organizations, 
     shall monitor and improve the quality of health care for 
     Indian women of all ages through the planning and delivery of 
     programs administered by the Service, in order to improve and 
     enhance the treatment models of care for Indian women.

     ``SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

       ``(a) Studies and Monitoring.--The Secretary and the 
     Service shall conduct, in conjunction with other appropriate 
     Federal agencies and in consultation with concerned Indian 
     Tribes and Tribal Organizations, studies and ongoing 
     monitoring programs to determine trends in the health hazards 
     to Indian miners and to Indians on or near reservations and 
     Indian communities as a result of environmental hazards which 
     may result in chronic or life threatening health problems, 
     such as nuclear resource development, petroleum 
     contamination, and contamination of water source and of the 
     food chain. Such studies shall include--
       ``(1) an evaluation of the nature and extent of health 
     problems caused by environmental hazards currently exhibited 
     among Indians and the causes of such health problems;
       ``(2) an analysis of the potential effect of ongoing and 
     future environmental resource development on or near 
     reservations and Indian communities, including the cumulative 
     effect over time on health;
       ``(3) an evaluation of the types and nature of activities, 
     practices, and conditions causing or affecting such health 
     problems, including uranium mining and milling, uranium mine 
     tailing deposits, nuclear power plant operation and 
     construction, and nuclear waste disposal; oil and gas 
     production or transportation on or near reservations or 
     Indian communities; and other development that could affect 
     the health of Indians and their water supply and food chain;
       ``(4) a summary of any findings and recommendations 
     provided in Federal and State studies, reports, 
     investigations, and inspections during the 5 years prior to 
     the date of enactment of the Indian Health Care Improvement 
     Act Amendments of 2009 that directly or indirectly relate to 
     the activities, practices, and conditions affecting the 
     health or safety of such Indians; and
       ``(5) the efforts that have been made by Federal and State 
     agencies and resource and economic development companies to 
     effectively carry out an education program for such Indians 
     regarding the health and safety hazards of such development.
       ``(b) Health Care Plans.--Upon completion of such studies, 
     the Secretary and the Service shall take into account the 
     results of such studies and develop health care plans to 
     address the health problems studied under subsection (a). The 
     plans shall include--
       ``(1) methods for diagnosing and treating Indians currently 
     exhibiting such health problems;
       ``(2) preventive care and testing for Indians who may be 
     exposed to such health hazards, including the monitoring of 
     the health of individuals who have or may have been exposed 
     to excessive amounts of radiation or affected by other 
     activities that have had or could have a serious impact upon 
     the health of such individuals; and
       ``(3) a program of education for Indians who, by reason of 
     their work or geographic proximity to such nuclear or other 
     development activities, may experience health problems.
       ``(c) Submission of Report and Plan to Congress.--The 
     Secretary and the Service shall submit to Congress the study 
     prepared under subsection (a) no later than 18 months after 
     the date of enactment of the Indian Health Care Improvement 
     Act Amendments of 2009. The health care plan prepared under 
     subsection (b) shall be submitted in a report no later than 1 
     year after the study prepared under subsection (a) is 
     submitted to Congress. Such report shall include recommended 
     activities for the implementation of the plan, as well as an 
     evaluation of any activities previously undertaken by the 
     Service to address such health problems.
       ``(d) Intergovernmental Task Force.--
       ``(1) Establishment; members.--There is established an 
     Intergovernmental Task Force to be composed of the following 
     individuals (or their designees):
       ``(A) The Secretary of Energy.
       ``(B) The Secretary of the Environmental Protection Agency.
       ``(C) The Director of the Bureau of Mines.
       ``(D) The Assistant Secretary for Occupational Safety and 
     Health.
       ``(E) The Secretary of the Interior.
       ``(F) The Secretary of Health and Human Services.
       ``(G) The Director of the Indian Health Service.
       ``(2) Duties.--The Task Force shall--
       ``(A) identify existing and potential operations related to 
     nuclear resource development or other environmental hazards 
     that affect or may affect the health of Indians on or near a 
     reservation or in an Indian community; and
       ``(B) enter into activities to correct existing health 
     hazards and ensure that current and future health problems 
     resulting from nuclear resource or other development 
     activities are minimized or reduced.
       ``(3) Chairman; meetings.--The Secretary of Health and 
     Human Services shall be the Chairman of the Task Force. The 
     Task Force shall meet at least twice each year.
       ``(e) Health Services to Certain Employees.--In the case of 
     any Indian who--
       ``(1) as a result of employment in or near a uranium mine 
     or mill or near any other environmental hazard, suffers from 
     a work-related illness or condition;
       ``(2) is eligible to receive diagnosis and treatment 
     services from an Indian Health Program; and
       ``(3) by reason of such Indian's employment, is entitled to 
     medical care at the expense of such mine or mill operator or 
     entity responsible for the environmental hazard, the Indian 
     Health Program shall, at the request of such Indian, render 
     appropriate medical care to such Indian for such illness or 
     condition and may be reimbursed for any medical care so 
     rendered to which such Indian is entitled at the expense of 
     such operator or entity from such operator or entity. Nothing 
     in this subsection shall affect the rights of such Indian to 
     recover damages other than such amounts paid to the Indian

[[Page 27407]]

     Health Program from the employer for providing medical care 
     for such illness or condition.

     ``SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY 
                   AREA.

       ``(a) In General.--For fiscal years beginning with the 
     fiscal year ending September 30, 1983, and ending with the 
     fiscal year ending September 30, 2025, the State of Arizona 
     shall be designated as a contract health service delivery 
     area by the Service for the purpose of providing contract 
     health care services to members of federally recognized 
     Indian Tribes of Arizona.
       ``(b) Maintenance of Services.--The Service shall not 
     curtail any health care services provided to Indians residing 
     on reservations in the State of Arizona if such curtailment 
     is due to the provision of contract services in such State 
     pursuant to the designation of such State as a contract 
     health service delivery area pursuant to subsection (a).

     ``SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH 
                   SERVICE DELIVERY AREA.

       ``(a) In General.--Beginning in fiscal year 2003, the 
     States of North Dakota and South Dakota shall be designated 
     as a contract health service delivery area by the Service for 
     the purpose of providing contract health care services to 
     members of federally recognized Indian Tribes of North Dakota 
     and South Dakota.
       ``(b) Limitation.--The Service shall not curtail any health 
     care services provided to Indians residing on any 
     reservation, or in any county that has a common boundary with 
     any reservation, in the State of North Dakota or South Dakota 
     if such curtailment is due to the provision of contract 
     services in such States pursuant to the designation of such 
     States as a contract health service delivery area pursuant to 
     subsection (a).

     ``SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

       ``(a) Funding Authorized.--The Secretary is authorized to 
     fund a program using an intertribal consortium as a contract 
     care intermediary to improve the accessibility of health 
     services to California Indians.
       ``(b) Reimbursement Contract.--The Secretary shall enter 
     into an agreement with the intertribal consortium to 
     reimburse the intertribal consortium for costs (including 
     reasonable administrative costs) incurred pursuant to this 
     section, in providing medical treatment under contract to 
     California Indians described in section 805(a) throughout the 
     California contract health services delivery area described 
     in section 219 with respect to high cost contract care cases.
       ``(c) Administrative Expenses.--Not more than 5 percent of 
     the amounts provided to the intertribal consortium under this 
     section for any fiscal year may be for reimbursement for 
     administrative expenses incurred by the intertribal 
     consortium during such fiscal year.
       ``(d) Limitation on Payment.--No payment may be made for 
     treatment provided hereunder to the extent payment may be 
     made for such treatment under the Indian Catastrophic Health 
     Emergency Fund described in section 202 or from amounts 
     appropriated or otherwise made available to the California 
     contract health service delivery area for a fiscal year.
       ``(e) Advisory Board.--There is established an advisory 
     board which shall advise the intertribal consortium in 
     carrying out this section. The advisory board shall be 
     composed of representatives, selected by the intertribal 
     consortium, from not less than 8 Tribal Health Programs 
     serving California Indians covered under this section at 
     least \1/2\ of whom are not affiliated with the intertribal 
     consortium.

     ``SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY 
                   AREA.

       ``The State of California, excluding the counties of 
     Alameda, Contra Costa, Los Angeles, Marin, Orange, 
     Sacramento, San Francisco, San Mateo, Santa Clara, Kern, 
     Merced, Monterey, Napa, San Benito, San Joaquin, San Luis 
     Obispo, Santa Cruz, Solano, Stanislaus, and Ventura, shall be 
     designated as a contract health service delivery area by the 
     Service for the purpose of providing contract health services 
     to California Indians. However, any of the counties listed 
     herein may only be included in the contract health services 
     delivery area if funding is specifically provided by the 
     Service for such services in those counties.

     ``SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE 
                   AREA.

       ``(a) Authorization for Services.--The Secretary, acting 
     through the Service, is directed to provide contract health 
     services to members of the Turtle Mountain Band of Chippewa 
     Indians that reside in the Trenton Service Area of Divide, 
     McKenzie, and Williams counties in the State of North Dakota 
     and the adjoining counties of Richland, Roosevelt, and 
     Sheridan in the State of Montana.
       ``(b) No Expansion of Eligibility.--Nothing in this section 
     may be construed as expanding the eligibility of members of 
     the Turtle Mountain Band of Chippewa Indians for health 
     services provided by the Service beyond the scope of 
     eligibility for such health services that applied on May 1, 
     1986.

     ``SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL 
                   ORGANIZATIONS.

       ``The Service shall provide funds for health care programs, 
     functions, services, activities, information technology, and 
     facilities operated by Tribal Health Programs on the same 
     basis as such funds are provided to programs, functions, 
     services, activities, information technology, and facilities 
     operated directly by the Service.

     ``SEC. 221. LICENSING.

       ``Licensed health care professionals employed by a Tribal 
     Health Program shall, if licensed in any State, be exempt 
     from the licensing requirements of the State in which the 
     Tribal Health Program performs the services described in its 
     contract or compact under the Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450 et seq.) while 
     performing such services.

     ``SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT 
                   HEALTH SERVICES.

       ``With respect to an elderly Indian or an Indian with a 
     disability receiving emergency medical care or services from 
     a non-Service provider or in a non-Service facility under the 
     authority of this Act, the time limitation (as a condition of 
     payment) for notifying the Service of such treatment or 
     admission shall be 30 days.

     ``SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

       ``(a) Deadline for Response.--The Service shall respond to 
     a notification of a claim by a provider of a contract care 
     service with either an individual purchase order or a denial 
     of the claim within 5 working days after the receipt of such 
     notification.
       ``(b) Effect of Untimely Response.--If the Service fails to 
     respond to a notification of a claim in accordance with 
     subsection (a), the Service shall accept as valid the claim 
     submitted by the provider of a contract care service.
       ``(c) Deadline for Payment of Valid Claim.--The Service 
     shall pay a valid contract care service claim within 30 days 
     after the completion of the claim.

     ``SEC. 224. LIABILITY FOR PAYMENT.

       ``(a) No Patient Liability.--A patient who receives 
     contract health care services that are authorized by the 
     Service shall not be liable for the payment of any charges or 
     costs associated with the provision of such services.
       ``(b) Notification.--The Secretary shall notify a contract 
     care provider and any patient who receives contract health 
     care services authorized by the Service that such patient is 
     not liable for the payment of any charges or costs associated 
     with the provision of such services not later than 5 business 
     days after receipt of a notification of a claim by a provider 
     of contract care services.
       ``(c) No Recourse.--Following receipt of the notice 
     provided under subsection (b), or, if a claim has been deemed 
     accepted under section 224(b), the provider shall have no 
     further recourse against the patient who received the 
     services.

     ``SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.

       ``(a) Establishment.--The Secretary may establish within 
     the Service an office to be known as the `Office of Indian 
     Men's Health' (referred to in this section as the `Office').
       ``(b) Director.--
       ``(1) In general.--The Office shall be headed by a 
     director, to be appointed by the Secretary.
       ``(2) Duties.--The director shall coordinate and promote 
     the status of the health of Indian men in the United States.
       ``(c) Report.--Not later than 2 years after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary, acting through the 
     director of the Office, shall submit to Congress a report 
     describing--
       ``(1) any activity carried out by the director as of the 
     date on which the report is prepared; and
       ``(2) any finding of the director with respect to the 
     health of Indian men.

     ``SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND.

       ``(a) Establishment.--There is established an Indian 
     Catastrophic Health Emergency Fund (hereafter in this section 
     referred to as the `CHEF') consisting of--
       ``(1) the amounts deposited under subsection (f); and
       ``(2) the amounts appropriated to CHEF under this section.
       ``(b) Administration.--CHEF shall be administered by the 
     Secretary, acting through the headquarters of the Service, 
     solely for the purpose of meeting the extraordinary medical 
     costs associated with the treatment of victims of disasters 
     or catastrophic illnesses who are within the responsibility 
     of the Service.
       ``(c) Conditions on Use of Fund.--No part of CHEF or its 
     administration shall be subject to contract or grant under 
     any law, including the Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450 et seq.), nor shall 
     CHEF funds be allocated, apportioned, or delegated on an Area 
     Office, Service Unit, or other similar basis.
       ``(d) Regulations.--The Secretary shall promulgate 
     regulations consistent with the provisions of this section 
     to--
       ``(1) establish a definition of disasters and catastrophic 
     illnesses for which the cost of the treatment provided under 
     contract would qualify for payment from CHEF;
       ``(2) provide that a Service Unit shall not be eligible for 
     reimbursement for the cost of

[[Page 27408]]

     treatment from CHEF until its cost of treating any victim of 
     such catastrophic illness or disaster has reached a certain 
     threshold cost which the Secretary shall establish at--
       ``(A) the 2000 level of $19,000; and
       ``(B) for any subsequent year, not less than the threshold 
     cost of the previous year increased by the percentage 
     increase in the medical care expenditure category of the 
     consumer price index for all urban consumers (United States 
     city average) for the 12-month period ending with December of 
     the previous year;
       ``(3) establish a procedure for the reimbursement of the 
     portion of the costs that exceeds such threshold cost 
     incurred by--
       ``(A) Service Units; or
       ``(B) whenever otherwise authorized by the Service, non-
     Service facilities or providers;
       ``(4) establish a procedure for payment from CHEF in cases 
     in which the exigencies of the medical circumstances warrant 
     treatment prior to the authorization of such treatment by the 
     Service; and
       ``(5) establish a procedure that will ensure that no 
     payment shall be made from CHEF to any provider of treatment 
     to the extent that such provider is eligible to receive 
     payment for the treatment from any other Federal, State, 
     local, or private source of reimbursement for which the 
     patient is eligible.
       ``(e) No Offset or Limitation.--Amounts appropriated to 
     CHEF under this section shall not be used to offset or limit 
     appropriations made to the Service under the authority of the 
     Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act'), or any other law.
       ``(f) Deposit of Reimbursement Funds.--There shall be 
     deposited into CHEF all reimbursements to which the Service 
     is entitled from any Federal, State, local, or private source 
     (including third party insurance) by reason of treatment 
     rendered to any victim of a disaster or catastrophic illness 
     the cost of which was paid from CHEF.

     ``SEC. 227. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated such sums as may 
     be necessary to carry out this title.

                        ``TITLE III--FACILITIES

     ``SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF 
                   FACILITIES; REPORTS.

       ``(a) Prerequisites for Expenditure of Funds.--Prior to the 
     expenditure of, or the making of any binding commitment to 
     expend, any funds appropriated for the planning, design, 
     construction, or renovation of facilities pursuant to the Act 
     of November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act'), the Secretary, acting through the Service, 
     shall--
       ``(1) consult with any Indian Tribe that would be 
     significantly affected by such expenditure for the purpose of 
     determining and, whenever practicable, honoring tribal 
     preferences concerning size, location, type, and other 
     characteristics of any facility on which such expenditure is 
     to be made; and
       ``(2) ensure, whenever practicable and applicable, that 
     such facility meets the construction standards of any 
     accrediting body recognized by the Secretary for the purposes 
     of the Medicare, Medicaid, and SCHIP programs under titles 
     XVIII, XIX, and XXI of the Social Security Act by not later 
     than 1 year after the date on which the construction or 
     renovation of such facility is completed.
       ``(b) Closures.--
       ``(1) Evaluation required.--Notwithstanding any other 
     provision of law, no facility operated by the Service may be 
     closed if the Secretary has not submitted to Congress, not 
     less than 1 year and not more than 2 years before the date of 
     the proposed closure, an evaluation, completed not more than 
     2 years before such submission, of the impact of the proposed 
     closure that specifies, in addition to other considerations--
       ``(A) the accessibility of alternative health care 
     resources for the population served by such facility;
       ``(B) the cost-effectiveness of such closure;
       ``(C) the quality of health care to be provided to the 
     population served by such facility after such closure;
       ``(D) the availability of contract health care funds to 
     maintain existing levels of service;
       ``(E) the views of the Indian Tribes served by such 
     facility concerning such closure;
       ``(F) the level of use of such facility by all eligible 
     Indians; and
       ``(G) the distance between such facility and the nearest 
     operating Service hospital.
       ``(2) Exception for certain temporary closures.--Paragraph 
     (1) shall not apply to any temporary closure of a facility or 
     any portion of a facility if such closure is necessary for 
     medical, environmental, or construction safety reasons.
       ``(c) Health Care Facility Priority System.--
       ``(1) In general.--
       ``(A) Priority system.--The Secretary, acting through the 
     Service, shall maintain a health care facility priority 
     system, which--
       ``(i) shall be developed in consultation with Indian Tribes 
     and Tribal Organizations;
       ``(ii) shall give Indian Tribes' needs the highest 
     priority;
       ``(iii)(I) may include the lists required in paragraph 
     (2)(B)(ii); and
       ``(II) shall include the methodology required in paragraph 
     (2)(B)(v); and
       ``(III) may include such other facilities, and such 
     renovation or expansion needs of any health care facility, as 
     the Service, Indian Tribes, and Tribal Organizations may 
     identify; and
       ``(iv) shall provide an opportunity for the nomination of 
     planning, design, and construction projects by the Service, 
     Indian Tribes, and Tribal Organizations for consideration 
     under the priority system at least once every 3 years, or 
     more frequently as the Secretary determines to be 
     appropriate.
       ``(B) Needs of facilities under isdeaa agreements.--The 
     Secretary shall ensure that the planning, design, 
     construction, renovation, and expansion needs of Service and 
     non-Service facilities operated under contracts or compacts 
     in accordance with the Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450 et seq.) are fully 
     and equitably integrated into the health care facility 
     priority system.
       ``(C) Criteria for evaluating needs.--For purposes of this 
     subsection, the Secretary, in evaluating the needs of 
     facilities operated under a contract or compact under the 
     Indian Self-Determination and Education Assistance Act (25 
     U.S.C. 450 et seq.), shall use the criteria used by the 
     Secretary in evaluating the needs of facilities operated 
     directly by the Service.
       ``(D) Priority of certain projects protected.--The priority 
     of any project established under the construction priority 
     system in effect on the date of enactment of the Indian 
     Health Care Improvement Act Amendments of 2009 shall not be 
     affected by any change in the construction priority system 
     taking place after that date if the project--
       ``(i) was identified in the fiscal year 2008 Service budget 
     justification as--

       ``(I) 1 of the 10 top-priority inpatient projects;
       ``(II) 1 of the 10 top-priority outpatient projects;
       ``(III) 1 of the 10 top-priority staff quarters 
     developments; or
       ``(IV) 1 of the 10 top-priority Youth Regional Treatment 
     Centers;

       ``(ii) had completed both Phase I and Phase II of the 
     construction priority system in effect on the date of 
     enactment of such Act; or
       ``(iii) is not included in clause (i) or (ii) and is 
     selected, as determined by the Secretary--

       ``(I) on the initiative of the Secretary; or
       ``(II) pursuant to a request of an Indian Tribe or Tribal 
     Organization.

       ``(2) Report; contents.--
       ``(A) Initial comprehensive report.--
       ``(i) Definitions.--In this subparagraph:

       ``(I) Facilities appropriation advisory board.--The term 
     `Facilities Appropriation Advisory Board' means the advisory 
     board, comprised of 12 members representing Indian tribes and 
     2 members representing the Service, established at the 
     discretion of the Assistant Secretary--

       ``(aa) to provide advice and recommendations for policies 
     and procedures of the programs funded pursuant to facilities 
     appropriations; and
       ``(bb) to address other facilities issues.

       ``(II) Facilities needs assessment workgroup.--The term 
     `Facilities Needs Assessment Workgroup' means the workgroup 
     established at the discretion of the Assistant Secretary--

       ``(aa) to review the health care facilities construction 
     priority system; and
       ``(bb) to make recommendations to the Facilities 
     Appropriation Advisory Board for revising the priority 
     system.
       ``(ii) Initial report.--

       ``(I) In general.--Not later than 1 year after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary shall submit to the 
     Committee on Indian Affairs of the Senate and the Committee 
     on Natural Resources of the House of Representatives a report 
     that describes the comprehensive, national, ranked list of 
     all health care facilities needs for the Service, Indian 
     Tribes, and Tribal Organizations (including inpatient health 
     care facilities, outpatient health care facilities, 
     specialized health care facilities (such as for long-term 
     care and alcohol and drug abuse treatment), wellness centers, 
     staff quarters and hostels associated with health care 
     facilities, and the renovation and expansion needs, if any, 
     of such facilities) developed by the Service, Indian Tribes, 
     and Tribal Organizations for the Facilities Needs Assessment 
     Workgroup and the Facilities Appropriation Advisory Board.
       ``(II) Inclusions.--The initial report shall include--

       ``(aa) the methodology and criteria used by the Service in 
     determining the needs and establishing the ranking of the 
     facilities needs; and
       ``(bb) such other information as the Secretary determines 
     to be appropriate.
       ``(iii) Updates of report.--Beginning in calendar year 
     2011, the Secretary shall--

       ``(I) update the report under clause (ii) not less 
     frequently that once every 5 years; and
       ``(II) include the updated report in the appropriate annual 
     report under subparagraph (B) for submission to Congress 
     under section 801.

       ``(B) Annual reports.--The Secretary shall submit to the 
     President, for inclusion in the report required to be 
     transmitted to Congress under section 801, a report which 
     sets forth the following:

[[Page 27409]]

       ``(i) A description of the health care facility priority 
     system of the Service established under paragraph (1).
       ``(ii) Health care facilities lists, which may include--

       ``(I) the 10 top-priority inpatient health care facilities;
       ``(II) the 10 top-priority outpatient health care 
     facilities;
       ``(III) the 10 top-priority specialized health care 
     facilities (such as long-term care and alcohol and drug abuse 
     treatment);
       ``(IV) the 10 top-priority staff quarters developments 
     associated with health care facilities; and
       ``(V) the 10 top-priority hostels associated with health 
     care facilities.

       ``(iii) The justification for such order of priority.
       ``(iv) The projected cost of such projects.
       ``(v) The methodology adopted by the Service in 
     establishing priorities under its health care facility 
     priority system.
       ``(3) Requirements for preparation of reports.--In 
     preparing the report required under paragraph (2), the 
     Secretary shall--
       ``(A) consult with and obtain information on all health 
     care facilities needs from Indian Tribes, Tribal 
     Organizations, and urban Indian organizations; and
       ``(B) review the total unmet needs of all Indian Tribes, 
     Tribal Organizations, and urban Indian organizations for 
     health care facilities (including hostels and staff 
     quarters), including needs for renovation and expansion of 
     existing facilities.
       ``(d) Review of Methodology Used for Health Facilities 
     Construction Priority System.--
       ``(1) In general.--Not later than 1 year after the 
     establishment of the priority system under subsection 
     (c)(1)(A), the Comptroller General of the United States shall 
     prepare and finalize a report reviewing the methodologies 
     applied, and the processes followed, by the Service in making 
     each assessment of needs for the list under subsection 
     (c)(2)(A)(ii) and developing the priority system under 
     subsection (c)(1), including a review of--
       ``(A) the recommendations of the Facilities Appropriation 
     Advisory Board and the Facilities Needs Assessment Workgroup 
     (as those terms are defined in subsection (c)(2)(A)(i)); and
       ``(B) the relevant criteria used in ranking or prioritizing 
     facilities other than hospitals or clinics.
       ``(2) Submission to congress.--The Comptroller General of 
     the United States shall submit the report under paragraph (1) 
     to--
       ``(A) the Committees on Indian Affairs and Appropriations 
     of the Senate;
       ``(B) the Committees on Natural Resources and 
     Appropriations of the House of Representatives; and
       ``(C) the Secretary.
       ``(e) Funding Condition.--All funds appropriated under the 
     Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act'), for the planning, design, construction, or 
     renovation of health facilities for the benefit of 1 or more 
     Indian Tribes shall be subject to the provisions of the 
     Indian Self-Determination and Education Assistance Act (25 
     U.S.C. 450 et seq.).
       ``(f) Development of Innovative Approaches.--The Secretary 
     shall consult and cooperate with Indian Tribes, Tribal 
     Organizations, and urban Indian organizations in developing 
     innovative approaches to address all or part of the total 
     unmet need for construction of health facilities, including 
     those provided for in other sections of this title and other 
     approaches.

     ``SEC. 302. SANITATION FACILITIES.

       ``(a) Findings.--Congress finds the following:
       ``(1) The provision of sanitation facilities is primarily a 
     health consideration and function.
       ``(2) Indian people suffer an inordinately high incidence 
     of disease, injury, and illness directly attributable to the 
     absence or inadequacy of sanitation facilities.
       ``(3) The long-term cost to the United States of treating 
     and curing such disease, injury, and illness is substantially 
     greater than the short-term cost of providing sanitation 
     facilities and other preventive health measures.
       ``(4) Many Indian homes and Indian communities still lack 
     sanitation facilities.
       ``(5) It is in the interest of the United States, and it is 
     the policy of the United States, that all Indian communities 
     and Indian homes, new and existing, be provided with 
     sanitation facilities.
       ``(b) Facilities and Services.--In furtherance of the 
     findings made in subsection (a), Congress reaffirms the 
     primary responsibility and authority of the Service to 
     provide the necessary sanitation facilities and services as 
     provided in section 7 of the Act of August 5, 1954 (42 U.S.C. 
     2004a). Under such authority, the Secretary, acting through 
     the Service, is authorized to provide the following:
       ``(1) Financial and technical assistance to Indian Tribes, 
     Tribal Organizations, and Indian communities in the 
     establishment, training, and equipping of utility 
     organizations to operate and maintain sanitation facilities, 
     including the provision of existing plans, standard details, 
     and specifications available in the Department, to be used at 
     the option of the Indian Tribe, Tribal Organization, or 
     Indian community.
       ``(2) Ongoing technical assistance and training to Indian 
     Tribes, Tribal Organizations, and Indian communities in the 
     management of utility organizations which operate and 
     maintain sanitation facilities.
       ``(3) Priority funding for operation and maintenance 
     assistance for, and emergency repairs to, sanitation 
     facilities operated by an Indian Tribe, Tribal Organization 
     or Indian community when necessary to avoid an imminent 
     health threat or to protect the investment in sanitation 
     facilities and the investment in the health benefits gained 
     through the provision of sanitation facilities.
       ``(c) Funding.--Notwithstanding any other provision of 
     law--
       ``(1) the Secretary of Housing and Urban Development is 
     authorized to transfer funds appropriated under the Native 
     American Housing Assistance and Self-Determination Act of 
     1996 (25 U.S.C. 4101 et seq.) to the Secretary of Health and 
     Human Services;
       ``(2) the Secretary of Health and Human Services is 
     authorized to accept and use such funds for the purpose of 
     providing sanitation facilities and services for Indians 
     under section 7 of the Act of August 5, 1954 (42 U.S.C. 
     2004a);
       ``(3) unless specifically authorized when funds are 
     appropriated, the Secretary shall not use funds appropriated 
     under section 7 of the Act of August 5, 1954 (42 U.S.C. 
     2004a), to provide sanitation facilities to new homes 
     constructed using funds provided by the Department of Housing 
     and Urban Development;
       ``(4) the Secretary of Health and Human Services is 
     authorized to accept from any source, including Federal and 
     State agencies, funds for the purpose of providing sanitation 
     facilities and services and place these funds into contracts 
     or compacts under the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.);
       ``(5) except as otherwise prohibited by this section, the 
     Secretary may use funds appropriated under the authority of 
     section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to 
     fund up to 100 percent of the amount of an Indian Tribe's 
     loan obtained under any Federal program for new projects to 
     construct eligible sanitation facilities to serve Indian 
     homes;
       ``(6) except as otherwise prohibited by this section, the 
     Secretary may use funds appropriated under the authority of 
     section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to 
     meet matching or cost participation requirements under other 
     Federal and non-Federal programs for new projects to 
     construct eligible sanitation facilities;
       ``(7) all Federal agencies are authorized to transfer to 
     the Secretary funds identified, granted, loaned, or 
     appropriated whereby the Department's applicable policies, 
     rules, and regulations shall apply in the implementation of 
     such projects;
       ``(8) the Secretary of Health and Human Services shall 
     enter into interagency agreements with Federal and State 
     agencies for the purpose of providing financial assistance 
     for sanitation facilities and services under this Act;
       ``(9) the Secretary of Health and Human Services shall, by 
     regulation, establish standards applicable to the planning, 
     design, and construction of sanitation facilities funded 
     under this Act; and
       ``(10) the Secretary of Health and Human Services is 
     authorized to accept payments for goods and services 
     furnished by the Service from appropriate public authorities, 
     nonprofit organizations or agencies, or Indian Tribes, as 
     contributions by that authority, organization, agency, or 
     tribe to agreements made under section 7 of the Act of August 
     5, 1954 (42 U.S.C. 2004a), and such payments shall be 
     credited to the same or subsequent appropriation account as 
     funds appropriated under the authority of section 7 of the 
     Act of August 5, 1954 (42 U.S.C. 2004a).
       ``(d) Certain Capabilities Not Prerequisite.--The financial 
     and technical capability of an Indian Tribe, Tribal 
     Organization, or Indian community to safely operate, manage, 
     and maintain a sanitation facility shall not be a 
     prerequisite to the provision or construction of sanitation 
     facilities by the Secretary.
       ``(e) Financial Assistance.--The Secretary is authorized to 
     provide financial assistance to Indian Tribes, Tribal 
     Organizations, and Indian communities in an amount equal to 
     the Federal share of the costs of operating, managing, and 
     maintaining the facilities provided under the plan described 
     in subsection (h)(1)(F).
       ``(f) Operation, Management, and Maintenance of 
     Facilities.--The Indian Tribe has the primary responsibility 
     to establish, collect, and use reasonable user fees, or 
     otherwise set aside funding, for the purpose of operating, 
     managing, and maintaining sanitation facilities. If a 
     sanitation facility serving a community that is operated by 
     an Indian Tribe or Tribal Organization is threatened with 
     imminent failure and such operator lacks capacity to maintain 
     the integrity or the health benefits of the sanitation 
     facility, then the Secretary is authorized to assist the 
     Indian Tribe, Tribal Organization, or Indian community in the 
     resolution of the problem on a short-term basis through 
     cooperation with the emergency coordinator or

[[Page 27410]]

     by providing operation, management, and maintenance service.
       ``(g) ISDEAA Program Funded on Equal Basis.--Tribal Health 
     Programs shall be eligible (on an equal basis with programs 
     that are administered directly by the Service) for--
       ``(1) any funds appropriated pursuant to this section; and
       ``(2) any funds appropriated for the purpose of providing 
     sanitation facilities.
       ``(h) Report.--
       ``(1) Required; contents.--The Secretary, in consultation 
     with the Secretary of Housing and Urban Development, Indian 
     Tribes, Tribal Organizations, and tribally designated housing 
     entities (as defined in section 4 of the Native American 
     Housing Assistance and Self-Determination Act of 1996 (25 
     U.S.C. 4103)) shall submit to the President, for inclusion in 
     the report required to be transmitted to Congress under 
     section 801, a report which sets forth--
       ``(A) the current Indian sanitation facility priority 
     system of the Service;
       ``(B) the methodology for determining sanitation 
     deficiencies and needs;
       ``(C) the criteria on which the deficiencies and needs will 
     be evaluated;
       ``(D) the level of initial and final sanitation deficiency 
     for each type of sanitation facility for each project of each 
     Indian Tribe or Indian community;
       ``(E) the amount and most effective use of funds, derived 
     from whatever source, necessary to accommodate the sanitation 
     facilities needs of new homes assisted with funds under the 
     Native American Housing Assistance and Self-Determination Act 
     (25 U.S.C. 4101 et seq.), and to reduce the identified 
     sanitation deficiency levels of all Indian Tribes and Indian 
     communities to level I sanitation deficiency as defined in 
     paragraph (3)(A); and
       ``(F) a 10-year plan to provide sanitation facilities to 
     serve existing Indian homes and Indian communities and new 
     and renovated Indian homes.
       ``(2) Uniform methodology.--The methodology used by the 
     Secretary in determining, preparing cost estimates for, and 
     reporting sanitation deficiencies for purposes of paragraph 
     (1) shall be applied uniformly to all Indian Tribes and 
     Indian communities.
       ``(3) Sanitation deficiency levels.--For purposes of this 
     subsection, the sanitation deficiency levels for an 
     individual, Indian Tribe, or Indian community sanitation 
     facility to serve Indian homes are determined as follows:
       ``(A) A level I deficiency exists if a sanitation facility 
     serving an individual, Indian Tribe, or Indian community--
       ``(i) complies with all applicable water supply, pollution 
     control, and solid waste disposal laws; and
       ``(ii) deficiencies relate to routine replacement, repair, 
     or maintenance needs.
       ``(B) A level II deficiency exists if a sanitation facility 
     serving an individual, Indian Tribe, or Indian community 
     substantially or recently complied with all applicable water 
     supply, pollution control, and solid waste laws and any 
     deficiencies relate to--
       ``(i) small or minor capital improvements needed to bring 
     the facility back into compliance;
       ``(ii) capital improvements that are necessary to enlarge 
     or improve the facilities in order to meet the current needs 
     for domestic sanitation facilities; or
       ``(iii) the lack of equipment or training by an Indian 
     Tribe, Tribal Organization, or an Indian community to 
     properly operate and maintain the sanitation facilities.
       ``(C) A level III deficiency exists if a sanitation 
     facility serving an individual, Indian Tribe or Indian 
     community meets 1 or more of the following conditions--
       ``(i) water or sewer service in the home is provided by a 
     haul system with holding tanks and interior plumbing;
       ``(ii) major significant interruptions to water supply or 
     sewage disposal occur frequently, requiring major capital 
     improvements to correct the deficiencies; or
       ``(iii) there is no access to or no approved or permitted 
     solid waste facility available.
       ``(D) A level IV deficiency exists--
       ``(i) if a sanitation facility for an individual home, an 
     Indian Tribe, or an Indian community exists but--

       ``(I) lacks--

       ``(aa) a safe water supply system; or
       ``(bb) a waste disposal system;

       ``(II) contains no piped water or sewer facilities; or
       ``(III) has become inoperable due to a major component 
     failure; or

       ``(ii) if only a washeteria or central facility exists in 
     the community.
       ``(E) A level V deficiency exists in the absence of a 
     sanitation facility, where individual homes do not have 
     access to safe drinking water or adequate wastewater 
     (including sewage) disposal.
       ``(i) Definitions.--For purposes of this section, the 
     following terms apply:
       ``(1) Indian community.--The term `Indian community' means 
     a geographic area, a significant proportion of whose 
     inhabitants are Indians and which is served by or capable of 
     being served by a facility described in this section.
       ``(2) Sanitation facilities.--The terms `sanitation 
     facility' and `sanitation facilities' mean safe and adequate 
     water supply systems, sanitary sewage disposal systems, and 
     sanitary solid waste systems (and all related equipment and 
     support infrastructure).

     ``SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

       ``(a) Buy Indian Act.--The Secretary, acting through the 
     Service, may use the negotiating authority of section 23 of 
     the Act of June 25, 1910 (25 U.S.C. 47, commonly known as the 
     `Buy Indian Act'), to give preference to any Indian or any 
     enterprise, partnership, corporation, or other type of 
     business organization owned and controlled by an Indian or 
     Indians including former or currently federally recognized 
     Indian Tribes in the State of New York (hereinafter referred 
     to as an `Indian firm') in the construction and renovation of 
     Service facilities pursuant to section 301 and in the 
     construction of sanitation facilities pursuant to section 
     302. Such preference may be accorded by the Secretary unless 
     the Secretary finds, pursuant to regulations, that the 
     project or function to be contracted for will not be 
     satisfactory or such project or function cannot be properly 
     completed or maintained under the proposed contract. The 
     Secretary, in arriving at such a finding, shall consider 
     whether the Indian or Indian firm will be deficient with 
     respect to--
       ``(1) ownership and control by Indians;
       ``(2) equipment;
       ``(3) bookkeeping and accounting procedures;
       ``(4) substantive knowledge of the project or function to 
     be contracted for;
       ``(5) adequately trained personnel; or
       ``(6) other necessary components of contract performance.
       ``(b) Pay Rates.--For the purposes of implementing the 
     provisions of this title, the Secretary shall assure that the 
     rates of pay for personnel engaged in the construction or 
     renovation of facilities constructed or renovated in whole or 
     in part by funds made available pursuant to this title are 
     not less than the prevailing local wage rates for similar 
     work as determined in accordance with the Act of March 3, 
     1931 (40 U.S.C. 276a-276a-5, known as the Davis-Bacon Act).
       ``(c) Labor Standards.--For the purposes of implementing 
     the provisions of this title, contracts for the construction 
     or renovation of health care facilities, staff quarters, and 
     sanitation facilities, and related support infrastructure, 
     funded in whole or in part with funds made available pursuant 
     to this title, shall contain a provision requiring compliance 
     with subchapter IV of chapter 31 of title 40, United States 
     Code (commonly known as the `Davis-Bacon Act').

     ``SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.

       ``(a) In General.--Notwithstanding any other provision of 
     law, if the requirements of subsection (c) are met, the 
     Secretary, acting through the Service, is authorized to 
     accept any major expansion, renovation, or modernization by 
     any Indian Tribe or Tribal Organization of any Service 
     facility or of any other Indian health facility operated 
     pursuant to a contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.), including--
       ``(1) any plans or designs for such expansion, renovation, 
     or modernization; and
       ``(2) any expansion, renovation, or modernization for which 
     funds appropriated under any Federal law were lawfully 
     expended.
       ``(b) Priority List.--
       ``(1) In general.--The Secretary shall maintain a separate 
     priority list to address the needs for increased operating 
     expenses, personnel, or equipment for such facilities. The 
     methodology for establishing priorities shall be developed 
     through regulations. The list of priority facilities will be 
     revised annually in consultation with Indian Tribes and 
     Tribal Organizations.
       ``(2) Report.--The Secretary shall submit to the President, 
     for inclusion in the report required to be transmitted to 
     Congress under section 801, the priority list maintained 
     pursuant to paragraph (1).
       ``(c) Requirements.--The requirements of this subsection 
     are met with respect to any expansion, renovation, or 
     modernization if--
       ``(1) the Indian Tribe or Tribal Organization--
       ``(A) provides notice to the Secretary of its intent to 
     expand, renovate, or modernize; and
       ``(B) applies to the Secretary to be placed on a separate 
     priority list to address the needs of such new facilities for 
     increased operating expenses, personnel, or equipment; and
       ``(2) the expansion, renovation, or modernization--
       ``(A) is approved by the appropriate area director of the 
     Service for Federal facilities; and
       ``(B) is administered by the Indian Tribe or Tribal 
     Organization in accordance with any applicable regulations 
     prescribed by the Secretary with respect to construction or 
     renovation of Service facilities.
       ``(d) Additional Requirement for Expansion.--In addition to 
     the requirements under subsection (c), for any expansion, the 
     Indian Tribe or Tribal Organization shall provide to the 
     Secretary additional information pursuant to regulations, 
     including additional staffing, equipment, and other costs 
     associated with the expansion.

[[Page 27411]]

       ``(e) Closure or Conversion of Facilities.--If any Service 
     facility which has been expanded, renovated, or modernized by 
     an Indian Tribe or Tribal Organization under this section 
     ceases to be used as a Service facility during the 20-year 
     period beginning on the date such expansion, renovation, or 
     modernization is completed, such Indian Tribe or Tribal 
     Organization shall be entitled to recover from the United 
     States an amount which bears the same ratio to the value of 
     such facility at the time of such cessation as the value of 
     such expansion, renovation, or modernization (less the total 
     amount of any funds provided specifically for such facility 
     under any Federal program that were expended for such 
     expansion, renovation, or modernization) bore to the value of 
     such facility at the time of the completion of such 
     expansion, renovation, or modernization.

     ``SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND 
                   MODERNIZATION OF SMALL AMBULATORY CARE 
                   FACILITIES.

       ``(a) Grants.--
       ``(1) In general.--The Secretary, acting through the 
     Service, shall make grants to Indian Tribes and Tribal 
     Organizations for the construction, expansion, or 
     modernization of facilities for the provision of ambulatory 
     care services to eligible Indians (and noneligible persons 
     pursuant to subsections (b)(2) and (c)(1)(C)). A grant made 
     under this section may cover up to 100 percent of the costs 
     of such construction, expansion, or modernization. For the 
     purposes of this section, the term `construction' includes 
     the replacement of an existing facility.
       ``(2) Grant agreement required.--A grant under paragraph 
     (1) may only be made available to a Tribal Health Program 
     operating an Indian health facility (other than a facility 
     owned or constructed by the Service, including a facility 
     originally owned or constructed by the Service and 
     transferred to an Indian Tribe or Tribal Organization).
       ``(b) Use of Grant Funds.--
       ``(1) Allowable uses.--A grant awarded under this section 
     may be used for the construction, expansion, or modernization 
     (including the planning and design of such construction, 
     expansion, or modernization) of an ambulatory care facility--
       ``(A) located apart from a hospital;
       ``(B) not funded under section 301 or section 306; and
       ``(C) which, upon completion of such construction or 
     modernization will--
       ``(i) have a total capacity appropriate to its projected 
     service population;
       ``(ii) provide annually no fewer than 150 patient visits by 
     eligible Indians and other users who are eligible for 
     services in such facility in accordance with section 
     806(c)(2); and
       ``(iii) provide ambulatory care in a Service Area 
     (specified in the contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.)) with a population of no fewer than 1,500 eligible 
     Indians and other users who are eligible for services in such 
     facility in accordance with section 806(c)(2).
       ``(2) Additional allowable use.--The Secretary may also 
     reserve a portion of the funding provided under this section 
     and use those reserved funds to reduce an outstanding debt 
     incurred by Indian Tribes or Tribal Organizations for the 
     construction, expansion, or modernization of an ambulatory 
     care facility that meets the requirements under paragraph 
     (1). The provisions of this section shall apply, except that 
     such applications for funding under this paragraph shall be 
     considered separately from applications for funding under 
     paragraph (1).
       ``(3) Use only for certain portion of costs.--A grant 
     provided under this section may be used only for the cost of 
     that portion of a construction, expansion, or modernization 
     project that benefits the Service population identified above 
     in subsection (b)(1)(C) (ii) and (iii). The requirements of 
     clauses (ii) and (iii) of paragraph (1)(C) shall not apply to 
     an Indian Tribe or Tribal Organization applying for a grant 
     under this section for a health care facility located or to 
     be constructed on an island or when such facility is not 
     located on a road system providing direct access to an 
     inpatient hospital where care is available to the Service 
     population.
       ``(c) Grants.--
       ``(1) Application.--No grant may be made under this section 
     unless an application or proposal for the grant has been 
     approved by the Secretary in accordance with applicable 
     regulations and has set forth reasonable assurance by the 
     applicant that, at all times after the construction, 
     expansion, or modernization of a facility carried out using a 
     grant received under this section--
       ``(A) adequate financial support will be available for the 
     provision of services at such facility;
       ``(B) such facility will be available to eligible Indians 
     without regard to ability to pay or source of payment; and
       ``(C) such facility will, as feasible without diminishing 
     the quality or quantity of services provided to eligible 
     Indians, serve noneligible persons on a cost basis.
       ``(2) Priority.--In awarding grants under this section, the 
     Secretary shall give priority to Indian Tribes and Tribal 
     Organizations that demonstrate--
       ``(A) a need for increased ambulatory care services; and
       ``(B) insufficient capacity to deliver such services.
       ``(3) Peer review panels.--The Secretary may provide for 
     the establishment of peer review panels, as necessary, to 
     review and evaluate applications and proposals and to advise 
     the Secretary regarding such applications using the criteria 
     developed pursuant to subsection (a)(1).
       ``(d) Reversion of Facilities.--If any facility (or portion 
     thereof) with respect to which funds have been paid under 
     this section, ceases, at any time after completion of the 
     construction, expansion, or modernization carried out with 
     such funds, to be used for the purposes of providing health 
     care services to eligible Indians, all of the right, title, 
     and interest in and to such facility (or portion thereof) 
     shall transfer to the United States unless otherwise 
     negotiated by the Service and the Indian Tribe or Tribal 
     Organization.
       ``(e) Funding Nonrecurring.--Funding provided under this 
     section shall be nonrecurring and shall not be available for 
     inclusion in any individual Indian Tribe's tribal share for 
     an award under the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or 
     redesign thereunder.

     ``SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION 
                   PROJECT.

       ``(a) Health Care Demonstration Projects.--The Secretary, 
     acting through the Service, is authorized to make grants to, 
     and enter into construction contracts or construction project 
     agreements with, Indian Tribes or Tribal Organizations under 
     the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450 et seq.) for the purpose of carrying out a 
     health care delivery demonstration project to test 
     alternative means of delivering health care and services to 
     Indians through facilities.
       ``(b) Use of Funds.--The Secretary, in approving projects 
     pursuant to this section, may authorize such contracts for 
     the construction and renovation of hospitals, health centers, 
     health stations, and other facilities to deliver health care 
     services and is authorized to--
       ``(1) waive any leasing prohibition;
       ``(2) permit carryover of funds appropriated for the 
     provision of health care services;
       ``(3) permit the use of other available funds;
       ``(4) permit the use of funds or property donated from any 
     source for project purposes;
       ``(5) provide for the reversion of donated real or personal 
     property to the donor; and
       ``(6) permit the use of Service funds to match other funds, 
     including Federal funds.
       ``(c) Regulations.--The Secretary shall develop and 
     promulgate regulations, not later than 1 year after the date 
     of enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, for the review and approval of 
     applications submitted under this section.
       ``(d) Criteria.--The Secretary may approve projects that 
     meet the following criteria:
       ``(1) There is a need for a new facility or program or the 
     reorientation of an existing facility or program.
       ``(2) A significant number of Indians, including those with 
     low health status, will be served by the project.
       ``(3) The project has the potential to deliver services in 
     an efficient and effective manner.
       ``(4) The project is economically viable.
       ``(5) The Indian Tribe or Tribal Organization has the 
     administrative and financial capability to administer the 
     project.
       ``(6) The project is integrated with providers of related 
     health and social services and is coordinated with, and 
     avoids duplication of, existing services.
       ``(e) Peer Review Panels.--The Secretary may provide for 
     the establishment of peer review panels, as necessary, to 
     review and evaluate applications using the criteria developed 
     pursuant to subsection (d).
       ``(f) Priority.--The Secretary shall give priority to 
     applications for demonstration projects in each of the 
     following Service Units to the extent that such applications 
     are timely filed and meet the criteria specified in 
     subsection (d):
       ``(1) Cass Lake, Minnesota.
       ``(2) Mescalero, New Mexico.
       ``(3) Owyhee, Nevada.
       ``(4) Schurz, Nevada.
       ``(5) Ft. Yuma, California.
       ``(g) Technical Assistance.--The Secretary shall provide 
     such technical and other assistance as may be necessary to 
     enable applicants to comply with the provisions of this 
     section.
       ``(h) Service to Ineligible Persons.--Subject to section 
     806, the authority to provide services to persons otherwise 
     ineligible for the health care benefits of the Service and 
     the authority to extend hospital privileges in Service 
     facilities to non-Service health practitioners as provided in 
     section 806 may be included, subject to the terms of such 
     section, in any demonstration project approved pursuant to 
     this section.
       ``(i) Equitable Treatment.--For purposes of subsection 
     (d)(1), the Secretary shall, in evaluating facilities 
     operated under any contract or compact under the Indian Self-
     Determination and Education Assistance Act

[[Page 27412]]

     (25 U.S.C. 450 et seq.), use the same criteria that the 
     Secretary uses in evaluating facilities operated directly by 
     the Service.
       ``(j) Equitable Integration of Facilities.--The Secretary 
     shall ensure that the planning, design, construction, 
     renovation, and expansion needs of Service and non-Service 
     facilities which are the subject of a contract or compact 
     under the Indian Self-Determination and Education Assistance 
     Act (25 U.S.C. 450 et seq.) for health services are fully and 
     equitably integrated into the implementation of the health 
     care delivery demonstration projects under this section.

     ``SEC. 307. LAND TRANSFER.

       ``Notwithstanding any other provision of law, the Bureau of 
     Indian Affairs and all other agencies and departments of the 
     United States are authorized to transfer, at no cost, land 
     and improvements to the Service for the provision of health 
     care services. The Secretary is authorized to accept such 
     land and improvements for such purposes.

     ``SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

       ``The Secretary, acting through the Service, may enter into 
     leases, contracts, and other agreements with Indian Tribes 
     and Tribal Organizations which hold (1) title to, (2) a 
     leasehold interest in, or (3) a beneficial interest in (when 
     title is held by the United States in trust for the benefit 
     of an Indian Tribe) facilities used or to be used for the 
     administration and delivery of health services by an Indian 
     Health Program. Such leases, contracts, or agreements may 
     include provisions for construction or renovation and provide 
     for compensation to the Indian Tribe or Tribal Organization 
     of rental and other costs consistent with section 105(l) of 
     the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450j(l)) and regulations thereunder.

     ``SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN 
                   REPAYMENT.

       ``(a) In General.--The Secretary, in consultation with the 
     Secretary of the Treasury, Indian Tribes, and Tribal 
     Organizations, shall carry out a study to determine the 
     feasibility of establishing a loan fund to provide to Indian 
     Tribes and Tribal Organizations direct loans or guarantees 
     for loans for the construction of health care facilities, 
     including--
       ``(1) inpatient facilities;
       ``(2) outpatient facilities;
       ``(3) staff quarters;
       ``(4) hostels; and
       ``(5) specialized care facilities, such as behavioral 
     health and elder care facilities.
       ``(b) Determinations.--In carrying out the study under 
     subsection (a), the Secretary shall determine--
       ``(1) the maximum principal amount of a loan or loan 
     guarantee that should be offered to a recipient from the loan 
     fund;
       ``(2) the percentage of eligible costs, not to exceed 100 
     percent, that may be covered by a loan or loan guarantee from 
     the loan fund (including costs relating to planning, design, 
     financing, site land development, construction, 
     rehabilitation, renovation, conversion, improvements, medical 
     equipment and furnishings, and other facility-related costs 
     and capital purchase (but excluding staffing));
       ``(3) the cumulative total of the principal of direct loans 
     and loan guarantees, respectively, that may be outstanding at 
     any 1 time;
       ``(4) the maximum term of a loan or loan guarantee that may 
     be made for a facility from the loan fund;
       ``(5) the maximum percentage of funds from the loan fund 
     that should be allocated for payment of costs associated with 
     planning and applying for a loan or loan guarantee;
       ``(6) whether acceptance by the Secretary of an assignment 
     of the revenue of an Indian Tribe or Tribal Organization as 
     security for any direct loan or loan guarantee from the loan 
     fund would be appropriate;
       ``(7) whether, in the planning and design of health 
     facilities under this section, users eligible under section 
     806(c) may be included in any projection of patient 
     population;
       ``(8) whether funds of the Service provided through loans 
     or loan guarantees from the loan fund should be eligible for 
     use in matching other Federal funds under other programs;
       ``(9) the appropriateness of, and best methods for, 
     coordinating the loan fund with the health care priority 
     system of the Service under section 301; and
       ``(10) any legislative or regulatory changes required to 
     implement recommendations of the Secretary based on results 
     of the study.
       ``(c) Report.--Not later than September 30, 2010, the 
     Secretary shall submit to the Committee on Indian Affairs of 
     the Senate and the Committee on Natural Resources and the 
     Committee on Energy and Commerce of the House of 
     Representatives a report that describes--
       ``(1) the manner of consultation made as required by 
     subsection (a); and
       ``(2) the results of the study, including any 
     recommendations of the Secretary based on results of the 
     study.

     ``SEC. 310. TRIBAL LEASING.

       ``A Tribal Health Program may lease permanent structures 
     for the purpose of providing health care services without 
     obtaining advance approval in appropriation Acts.

     ``SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT 
                   VENTURE PROGRAM.

       ``(a) In General.--The Secretary, acting through the 
     Service, shall make arrangements with Indian Tribes and 
     Tribal Organizations to establish joint venture demonstration 
     projects under which an Indian Tribe or Tribal Organization 
     shall expend tribal, private, or other available funds, for 
     the acquisition or construction of a health facility for a 
     minimum of 10 years, under a no-cost lease, in exchange for 
     agreement by the Service to provide the equipment, supplies, 
     and staffing for the operation and maintenance of such a 
     health facility. An Indian Tribe or Tribal Organization may 
     use tribal funds, private sector, or other available 
     resources, including loan guarantees, to fulfill its 
     commitment under a joint venture entered into under this 
     subsection. An Indian Tribe or Tribal Organization shall be 
     eligible to establish a joint venture project if, when it 
     submits a letter of intent, it--
       ``(1) has begun but not completed the process of 
     acquisition or construction of a health facility to be used 
     in the joint venture project;
       ``(2) has not begun the process of acquisition or 
     construction of a health facility for use in the joint 
     venture project; or
       ``(3) in its application for a joint venture agreement, 
     agrees--
       ``(A) to construct a facility for the joint venture which 
     complies with the size and space criteria established by the 
     Service; or
       ``(B) if the facility it proposes for the joint venture is 
     already in existence or under construction, that only the 
     portion of such facility which complies with the size and 
     space criteria of the Service will be eligible for the joint 
     venture agreement.
       ``(b) Requirements.--The Secretary shall make such an 
     arrangement with an Indian Tribe or Tribal Organization only 
     if--
       ``(1) the Secretary first determines that the Indian Tribe 
     or Tribal Organization has the administrative and financial 
     capabilities necessary to complete the timely acquisition or 
     construction of the relevant health facility; and
       ``(2) the Indian Tribe or Tribal Organization meets the 
     need criteria determined using the criteria developed under 
     the health care facility priority system under section 301, 
     unless the Secretary determines, pursuant to regulations, 
     that other criteria will result in a more cost-effective and 
     efficient method of facilitating and completing construction 
     of health care facilities.
       ``(c) Continued Operation.--The Secretary shall negotiate 
     an agreement with the Indian Tribe or Tribal Organization 
     regarding the continued operation of the facility at the end 
     of the initial 10 year no-cost lease period.
       ``(d) Breach of Agreement.--An Indian Tribe or Tribal 
     Organization that has entered into a written agreement with 
     the Secretary under this section, and that breaches or 
     terminates without cause such agreement, shall be liable to 
     the United States for the amount that has been paid to the 
     Indian Tribe or Tribal Organization, or paid to a third party 
     on the Indian Tribe's or Tribal Organization's behalf, under 
     the agreement. The Secretary has the right to recover 
     tangible property (including supplies) and equipment, less 
     depreciation, and any funds expended for operations and 
     maintenance under this section. The preceding sentence does 
     not apply to any funds expended for the delivery of health 
     care services, personnel, or staffing.
       ``(e) Recovery for Nonuse.--An Indian Tribe or Tribal 
     Organization that has entered into a written agreement with 
     the Secretary under this subsection shall be entitled to 
     recover from the United States an amount that is proportional 
     to the value of such facility if, at any time within the 10-
     year term of the agreement, the Service ceases to use the 
     facility or otherwise breaches the agreement.
       ``(f) Definition.--For the purposes of this section, the 
     term `health facility' or `health facilities' includes 
     quarters needed to provide housing for staff of the relevant 
     Tribal Health Program.

     ``SEC. 312. LOCATION OF FACILITIES.

       ``(a) In General.--In all matters involving the 
     reorganization or development of Service facilities or in the 
     establishment of related employment projects to address 
     unemployment conditions in economically depressed areas, the 
     Bureau of Indian Affairs and the Service shall give priority 
     to locating such facilities and projects on Indian lands, or 
     lands in Alaska owned by any Alaska Native village, or 
     village or regional corporation under the Alaska Native 
     Claims Settlement Act (43 U.S.C. 1601 et seq.), or any land 
     allotted to any Alaska Native, if requested by the Indian 
     owner and the Indian Tribe with jurisdiction over such lands 
     or other lands owned or leased by the Indian Tribe or Tribal 
     Organization. Top priority shall be given to Indian land 
     owned by 1 or more Indian Tribes.
       ``(b) Definition.--For purposes of this section, the term 
     `Indian lands' means--
       ``(1) all lands within the exterior boundaries of any 
     reservation; and
       ``(2) any lands title to which is held in trust by the 
     United States for the benefit of any Indian Tribe or 
     individual Indian or held by any Indian Tribe or individual 
     Indian subject to restriction by the United States against 
     alienation.

[[Page 27413]]



     ``SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE 
                   FACILITIES.

       ``(a) Report.--The Secretary shall submit to the President, 
     for inclusion in the report required to be transmitted to 
     Congress under section 801, a report which identifies the 
     backlog of maintenance and repair work required at both 
     Service and tribal health care facilities, including new 
     health care facilities expected to be in operation in the 
     next fiscal year. The report shall also identify the need for 
     renovation and expansion of existing facilities to support 
     the growth of health care programs.
       ``(b) Maintenance of Newly Constructed Space.--The 
     Secretary, acting through the Service, is authorized to 
     expend maintenance and improvement funds to support 
     maintenance of newly constructed space only if such space 
     falls within the approved supportable space allocation for 
     the Indian Tribe or Tribal Organization. Supportable space 
     allocation shall be defined through the health care facility 
     priority system under section 301(c).
       ``(c) Replacement Facilities.--In addition to using 
     maintenance and improvement funds for renovation, 
     modernization, and expansion of facilities, an Indian Tribe 
     or Tribal Organization may use maintenance and improvement 
     funds for construction of a replacement facility if the costs 
     of renovation of such facility would exceed a maximum 
     renovation cost threshold. The Secretary shall consult with 
     Indian Tribes and Tribal Organizations in determining the 
     maximum renovation cost threshold.

     ``SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS.

       ``(a) Rental Rates.--
       ``(1) Establishment.--Notwithstanding any other provision 
     of law, a Tribal Health Program which operates a hospital or 
     other health facility and the federally owned quarters 
     associated therewith pursuant to a contract or compact under 
     the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450 et seq.) shall have the authority to establish 
     the rental rates charged to the occupants of such quarters by 
     providing notice to the Secretary of its election to exercise 
     such authority.
       ``(2) Objectives.--In establishing rental rates pursuant to 
     authority of this subsection, a Tribal Health Program shall 
     endeavor to achieve the following objectives:
       ``(A) To base such rental rates on the reasonable value of 
     the quarters to the occupants thereof.
       ``(B) To generate sufficient funds to prudently provide for 
     the operation and maintenance of the quarters, and subject to 
     the discretion of the Tribal Health Program, to supply 
     reserve funds for capital repairs and replacement of the 
     quarters.
       ``(3) Equitable funding.--Any quarters whose rental rates 
     are established by a Tribal Health Program pursuant to this 
     subsection shall remain eligible for quarters improvement and 
     repair funds to the same extent as all federally owned 
     quarters used to house personnel in Services-supported 
     programs.
       ``(4) Notice of rate change.--A Tribal Health Program which 
     exercises the authority provided under this subsection shall 
     provide occupants with no less than 60 days notice of any 
     change in rental rates.
       ``(b) Direct Collection of Rent.--
       ``(1) In general.--Notwithstanding any other provision of 
     law, and subject to paragraph (2), a Tribal Health Program 
     shall have the authority to collect rents directly from 
     Federal employees who occupy such quarters in accordance with 
     the following:
       ``(A) The Tribal Health Program shall notify the Secretary 
     and the subject Federal employees of its election to exercise 
     its authority to collect rents directly from such Federal 
     employees.
       ``(B) Upon receipt of a notice described in subparagraph 
     (A), the Federal employees shall pay rents for occupancy of 
     such quarters directly to the Tribal Health Program and the 
     Secretary shall have no further authority to collect rents 
     from such employees through payroll deduction or otherwise.
       ``(C) Such rent payments shall be retained by the Tribal 
     Health Program and shall not be made payable to or otherwise 
     be deposited with the United States.
       ``(D) Such rent payments shall be deposited into a separate 
     account which shall be used by the Tribal Health Program for 
     the maintenance (including capital repairs and replacement) 
     and operation of the quarters and facilities as the Tribal 
     Health Program shall determine.
       ``(2) Retrocession of authority.--If a Tribal Health 
     Program which has made an election under paragraph (1) 
     requests retrocession of its authority to directly collect 
     rents from Federal employees occupying federally owned 
     quarters, such retrocession shall become effective on the 
     earlier of--
       ``(A) the first day of the month that begins no less than 
     180 days after the Tribal Health Program notifies the 
     Secretary of its desire to retrocede; or
       ``(B) such other date as may be mutually agreed by the 
     Secretary and the Tribal Health Program.
       ``(c) Rates in Alaska.--To the extent that a Tribal Health 
     Program, pursuant to authority granted in subsection (a), 
     establishes rental rates for federally owned quarters 
     provided to a Federal employee in Alaska, such rents may be 
     based on the cost of comparable private rental housing in the 
     nearest established community with a year-round population of 
     1,500 or more individuals.

     ``SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

       ``(a) Applicability.--The Secretary shall ensure that the 
     requirements of the Buy American Act apply to all 
     procurements made with funds provided pursuant to section 
     317. Indian Tribes and Tribal Organizations shall be exempt 
     from these requirements.
       ``(b) Effect of Violation.--If it has been finally 
     determined by a court or Federal agency that any person 
     intentionally affixed a label bearing a `Made in America' 
     inscription or any inscription with the same meaning, to any 
     product sold in or shipped to the United States that is not 
     made in the United States, such person shall be ineligible to 
     receive any contract or subcontract made with funds provided 
     pursuant to section 317, pursuant to the debarment, 
     suspension, and ineligibility procedures described in 
     sections 9.400 through 9.409 of title 48, Code of Federal 
     Regulations.
       ``(c) Definitions.--For purposes of this section, the term 
     `Buy American Act' means title III of the Act entitled `An 
     Act making appropriations for the Treasury and Post Office 
     Departments for the fiscal year ending June 30, 1934, and for 
     other purposes', approved March 3, 1933 (41 U.S.C. 10a et 
     seq.).

     ``SEC. 316. OTHER FUNDING FOR FACILITIES.

       ``(a) Authority To Accept Funds.--The Secretary is 
     authorized to accept from any source, including Federal and 
     State agencies, funds that are available for the construction 
     of health care facilities and use such funds to plan, design, 
     and construct health care facilities for Indians and to place 
     such funds into a contract or compact under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.). Receipt of such funds shall have no effect on the 
     priorities established pursuant to section 301.
       ``(b) Interagency Agreements.--The Secretary is authorized 
     to enter into interagency agreements with other Federal 
     agencies or State agencies and other entities and to accept 
     funds from such Federal or State agencies or other sources to 
     provide for the planning, design, and construction of health 
     care facilities to be administered by Indian Health Programs 
     in order to carry out the purposes of this Act and the 
     purposes for which the funds were appropriated or for which 
     the funds were otherwise provided.
       ``(c) Transferred Funds.--Any Federal agency to which funds 
     for the construction of health care facilities are 
     appropriated is authorized to transfer such funds to the 
     Secretary for the construction of health care facilities to 
     carry out the purposes of this Act as well as the purposes 
     for which such funds are appropriated to such other Federal 
     agency.
       ``(d) Establishment of Standards.--The Secretary, through 
     the Service, shall establish standards by regulation for the 
     planning, design, and construction of health care facilities 
     serving Indians under this Act.

     ``SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated such sums as may 
     be necessary to carry out this title.

                 ``TITLE IV--ACCESS TO HEALTH SERVICES

     ``SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT 
                   HEALTH BENEFITS PROGRAMS.

       ``(a) Disregard of Medicare, Medicaid, and SCHIP Payments 
     in Determining Appropriations.--Any payments received by an 
     Indian Health Program or by an urban Indian organization 
     under title XVIII, XIX, or XXI of the Social Security Act for 
     services provided to Indians eligible for benefits under such 
     respective titles shall not be considered in determining 
     appropriations for the provision of health care and services 
     to Indians.
       ``(b) Nonpreferential Treatment.--Nothing in this Act 
     authorizes the Secretary to provide services to an Indian 
     with coverage under title XVIII, XIX, or XXI of the Social 
     Security Act in preference to an Indian without such 
     coverage.
       ``(c) Use of Funds.--
       ``(1) Special fund.--
       ``(A) 100 percent pass-through of payments due to 
     facilities.--Notwithstanding any other provision of law, but 
     subject to paragraph (2), payments to which a facility of the 
     Service is entitled by reason of a provision of title XVIII 
     or XIX of the Social Security Act shall be placed in a 
     special fund to be held by the Secretary. In making payments 
     from such fund, the Secretary shall ensure that each Service 
     Unit of the Service receives 100 percent of the amount to 
     which the facilities of the Service, for which such Service 
     Unit makes collections, are entitled by reason of a provision 
     of either such title.
       ``(B) Use of funds.--Amounts received by a facility of the 
     Service under subparagraph (A) by reason of a provision of 
     title XVIII or XIX of the Social Security Act shall first be 
     used (to such extent or in such amounts as are provided in 
     appropriation Acts) for the purpose of making any 
     improvements in the programs of the Service operated by or 
     through such facility which may be necessary to achieve or 
     maintain compliance with the applicable conditions and 
     requirements of such respective title. Any amounts

[[Page 27414]]

     so received that are in excess of the amount necessary to 
     achieve or maintain such conditions and requirements shall, 
     subject to consultation with the Indian Tribes being served 
     by the Service Unit, be used for increasing the facility's 
     capacity to provide, or improving the quality or 
     accessibility of, services.
       ``(2) Direct payment option.--Paragraph (1) shall not apply 
     to a Tribal Health Program upon the election of such Program 
     under subsection (d) to receive payments directly. No payment 
     may be made out of the special fund described in such 
     paragraph with respect to reimbursement made for services 
     provided by such Program during the period of such election.
       ``(d) Direct Billing.--
       ``(1) In general.--Subject to complying with the 
     requirements of paragraph (2), a Tribal Health Program may 
     elect to directly bill for, and receive payment for, health 
     care items and services provided by such Program for which 
     payment is made under title XVIII, XIX, or XXI of the Social 
     Security Act.
       ``(2) Direct reimbursement.--
       ``(A) Use of funds.--Each Tribal Health Program making the 
     election described in paragraph (1) with respect to a program 
     under title XVIII, XIX, or XXI of the Social Security Act 
     shall be reimbursed directly by that program for items and 
     services furnished without regard to subsection (c)(1), but 
     all amounts so reimbursed shall be used by the Tribal Health 
     Program for the same purposes with respect to such Program 
     for which payment under subparagraph (A) of subsection (c)(1) 
     to a facility of the Service may be used pursuant to 
     subparagraph (B) of such subsection with respect to the 
     Service.
       ``(B) Audits.--The amounts paid to a Tribal Health Program 
     making the election described in paragraph (1) with respect 
     to a program under title XVIII, XIX, or XXI of the Social 
     Security Act shall be subject to all auditing requirements 
     applicable to the program under such title, as well as all 
     auditing requirements applicable to programs administered by 
     an Indian Health Program. Nothing in the preceding sentence 
     shall be construed as limiting the application of auditing 
     requirements applicable to amounts paid under title XVIII, 
     XIX, or XXI of the Social Security Act.
       ``(C) Identification of source of payments.--Any Tribal 
     Health Program that receives reimbursements or payments under 
     title XVIII, XIX, or XXI of the Social Security Act shall 
     provide to the Service a list of each provider enrollment 
     number (or other identifier) under which such Program 
     receives such reimbursements or payments.
       ``(3) Examination and implementation of changes.--
       ``(A) In general.--The Secretary, acting through the 
     Service and with the assistance of the Administrator of the 
     Centers for Medicare & Medicaid Services, shall examine on an 
     ongoing basis and implement any administrative changes that 
     may be necessary to facilitate direct billing and 
     reimbursement under the program established under this 
     subsection, including any agreements with States that may be 
     necessary to provide for direct billing under a program under 
     title XIX or XXI of the Social Security Act.
       ``(B) Coordination of information.--The Service shall 
     provide the Administrator of the Centers for Medicare & 
     Medicaid Services with copies of the lists submitted to the 
     Service under paragraph (2)(C), enrollment data regarding 
     patients served by the Service (and by Tribal Health 
     Programs, to the extent such data is available to the 
     Service), and such other information as the Administrator may 
     require for purposes of administering title XVIII, XIX, or 
     XXI of the Social Security Act.
       ``(4) Withdrawal from program.--A Tribal Health Program 
     that bills directly under the program established under this 
     subsection may withdraw from participation in the same manner 
     and under the same conditions that an Indian Tribe or Tribal 
     Organization may retrocede a contracted program to the 
     Secretary under the authority of the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.). All cost accounting and billing authority under the 
     program established under this subsection shall be returned 
     to the Secretary upon the Secretary's acceptance of the 
     withdrawal of participation in this program.
       ``(5) Termination for failure to comply with 
     requirements.--The Secretary may terminate the participation 
     of a Tribal Health Program or in the direct billing program 
     established under this subsection if the Secretary determines 
     that the Program has failed to comply with the requirements 
     of paragraph (2). The Secretary shall provide a Tribal Health 
     Program with notice of a determination that the Program has 
     failed to comply with any such requirement and a reasonable 
     opportunity to correct such noncompliance prior to 
     terminating the Program's participation in the direct billing 
     program established under this subsection.
       ``(e) Related Provisions Under the Social Security Act.--
     For provisions related to subsections (c) and (d), see 
     sections 1880, 1911, and 2107(e)(1)(D) of the Social Security 
     Act.

     ``SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN 
                   TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN 
                   ORGANIZATIONS TO FACILITATE OUTREACH, 
                   ENROLLMENT, AND COVERAGE OF INDIANS UNDER 
                   SOCIAL SECURITY ACT HEALTH BENEFIT PROGRAMS.

       ``(a) Indian Tribes and Tribal Organizations.--The 
     Secretary, acting through the Service, shall make grants to 
     or enter into contracts with Indian Tribes and Tribal 
     Organizations to assist such Tribes and Tribal Organizations 
     in establishing and administering programs on or near 
     reservations, trust lands, and Alaska Native Villages, 
     including programs to provide outreach and enrollment through 
     video, electronic delivery methods, or telecommunication 
     devices that allow real-time or time-delayed communication 
     between individual Indians and the benefit program, to assist 
     individual Indians--
       ``(1) to enroll for benefits under a program established 
     under title XVIII, XIX, or XXI of the Social Security Act; 
     and
       ``(2) with respect to such programs for which the charging 
     of premiums and cost sharing is not prohibited under such 
     programs, to pay premiums or cost sharing for coverage for 
     such benefits, which may be based on financial need (as 
     determined by the Indian Tribe or Tribes or Tribal 
     Organizations being served based on a schedule of income 
     levels developed or implemented by such Tribe, Tribes, or 
     Tribal Organizations).
       ``(b) Conditions.--The Secretary, acting through the 
     Service, shall place conditions as deemed necessary to effect 
     the purpose of this section in any grant or contract which 
     the Secretary makes with any Indian Tribe or Tribal 
     Organization pursuant to this section. Such conditions shall 
     include requirements that the Indian Tribe or Tribal 
     Organization successfully undertake--
       ``(1) to determine the population of Indians eligible for 
     the benefits described in subsection (a);
       ``(2) to educate Indians with respect to the benefits 
     available under the respective programs;
       ``(3) to provide transportation for such individual Indians 
     to the appropriate offices for enrollment or applications for 
     such benefits; and
       ``(4) to develop and implement methods of improving the 
     participation of Indians in receiving benefits under such 
     programs.
       ``(c) Application to Urban Indian Organizations.--
       ``(1) In general.--The provisions of subsection (a) shall 
     apply with respect to grants and other funding to urban 
     Indian organizations with respect to populations served by 
     such organizations in the same manner they apply to grants 
     and contracts with Indian Tribes and Tribal Organizations 
     with respect to programs on or near reservations.
       ``(2) Requirements.--The Secretary shall include in the 
     grants or contracts made or provided under paragraph (1) 
     requirements that are--
       ``(A) consistent with the requirements imposed by the 
     Secretary under subsection (b);
       ``(B) appropriate to urban Indian organizations and urban 
     Indians; and
       ``(C) necessary to effect the purposes of this section.
       ``(d) Facilitating Cooperation in Enrollment and 
     Retention.--The Secretary, acting through the Centers for 
     Medicare & Medicaid Services, shall consult with States, the 
     Service, Indian Tribes, Tribal Organizations, and urban 
     Indian organizations to develop and disseminate best 
     practices with respect to facilitating agreements between the 
     States and Indian Tribes, Tribal Organizations, and urban 
     Indian organizations relating to enrollment and retention of 
     Indians in programs established under titles XVIII, XIX, and 
     XXI of the Social Security Act.
       ``(e) Agreements To Improve Enrollment of Indians Under 
     Social Security Act Health Benefits Programs.--For provisions 
     relating to agreements between the Secretary and the Service, 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations for the collection, preparation, and submission 
     of applications by Indians for assistance under the Medicaid 
     and children's health insurance programs established under 
     titles XIX and XXI of the Social Security Act, and benefits 
     under the Medicare program established under title XVIII of 
     such Act, see subsections (a) and (b) of section 1139 of the 
     Social Security Act.
       ``(f) Definitions.--In this section:
       ``(1) Premium.--The term `premium' includes any enrollment 
     fee or similar charge.
       ``(2) Cost sharing.--The term `cost sharing' includes any 
     deduction, deductible, copayment, coinsurance, or similar 
     charge.
       ``(3) Benefits.--The term `benefits' means, with respect 
     to--
       ``(A) title XVIII of the Social Security Act, benefits 
     under such title;
       ``(B) title XIX of such Act, medical assistance under such 
     title; and
       ``(C) title XXI of such Act, assistance under such title.

     ``SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS 
                   OF HEALTH SERVICES.

       ``(a) Right of Recovery.--Except as provided in subsection 
     (f), the United States, an Indian Tribe, or Tribal 
     Organization shall have the right to recover from an 
     insurance company, health maintenance organization, employee 
     benefit plan, third-party tortfeasor, or any other 
     responsible or liable third party (including a political 
     subdivision or local governmental entity of a State) the

[[Page 27415]]

     reasonable charges incurred by the Secretary, an Indian 
     Tribe, or Tribal Organization, or, if higher, the highest 
     amount the third party would pay for care and services 
     furnished by providers other than governmental entities, in 
     providing health services through the Service, an Indian 
     Tribe, or Tribal Organization to any individual to the same 
     extent that such individual, or any nongovernmental provider 
     of such services, would be eligible to receive damages, 
     reimbursement, or indemnification for such charges if--
       ``(1) such services had been provided by a nongovernmental 
     provider; and
       ``(2) such individual had been required to pay such charges 
     or expenses and did pay such charges or expenses.
       ``(b) Limitations on Recoveries From States.--Subsection 
     (a) shall provide a right of recovery against any State, only 
     if the injury, illness, or disability for which health 
     services were provided is covered under--
       ``(1) workers' compensation laws; or
       ``(2) a no-fault automobile accident insurance plan or 
     program.
       ``(c) Nonapplication of Other Laws.--No law of any State, 
     or of any political subdivision of a State and no provision 
     of any contract, insurance or health maintenance organization 
     policy, employee benefit plan, self-insurance plan, managed 
     care plan, or other health care plan or program entered into 
     or renewed after the date of the enactment of the Indian 
     Health Care Amendments of 1988, shall prevent or hinder the 
     right of recovery of the United States, an Indian Tribe, or 
     Tribal Organization under subsection (a).
       ``(d) No Effect on Private Rights of Action.--No action 
     taken by the United States, an Indian Tribe, or Tribal 
     Organization to enforce the right of recovery provided under 
     this section shall operate to deny to the injured person the 
     recovery for that portion of the person's damage not covered 
     hereunder.
       ``(e) Enforcement.--
       ``(1) In general.--The United States, an Indian Tribe, or 
     Tribal Organization may enforce the right of recovery 
     provided under subsection (a) by--
       ``(A) intervening or joining in any civil action or 
     proceeding brought--
       ``(i) by the individual for whom health services were 
     provided by the Secretary, an Indian Tribe, or Tribal 
     Organization; or
       ``(ii) by any representative or heirs of such individual, 
     or
       ``(B) instituting a civil action, including a civil action 
     for injunctive relief and other relief and including, with 
     respect to a political subdivision or local governmental 
     entity of a State, such an action against an official 
     thereof.
       ``(2) Notice.--All reasonable efforts shall be made to 
     provide notice of action instituted under paragraph (1)(B) to 
     the individual to whom health services were provided, either 
     before or during the pendency of such action.
       ``(3) Recovery from tortfeasors.--
       ``(A) In general.--In any case in which an Indian Tribe or 
     Tribal Organization that is authorized or required under a 
     compact or contract issued pursuant to the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.) to furnish or pay for health services to a person who 
     is injured or suffers a disease on or after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009 under circumstances that establish grounds 
     for a claim of liability against the tortfeasor with respect 
     to the injury or disease, the Indian Tribe or Tribal 
     Organization shall have a right to recover from the 
     tortfeasor (or an insurer of the tortfeasor) the reasonable 
     value of the health services so furnished, paid for, or to be 
     paid for, in accordance with the Federal Medical Care 
     Recovery Act (42 U.S.C. 2651 et seq.), to the same extent and 
     under the same circumstances as the United States may recover 
     under that Act.
       ``(B) Treatment.--The right of an Indian Tribe or Tribal 
     Organization to recover under subparagraph (A) shall be 
     independent of the rights of the injured or diseased person 
     served by the Indian Tribe or Tribal Organization.
       ``(f) Limitation.--Absent specific written authorization by 
     the governing body of an Indian Tribe for the period of such 
     authorization (which may not be for a period of more than 1 
     year and which may be revoked at any time upon written notice 
     by the governing body to the Service), the United States 
     shall not have a right of recovery under this section if the 
     injury, illness, or disability for which health services were 
     provided is covered under a self-insurance plan funded by an 
     Indian Tribe, Tribal Organization, or urban Indian 
     organization. Where such authorization is provided, the 
     Service may receive and expend such amounts for the provision 
     of additional health services consistent with such 
     authorization.
       ``(g) Costs and Attorneys' Fees.--In any action brought to 
     enforce the provisions of this section, a prevailing 
     plaintiff shall be awarded its reasonable attorneys' fees and 
     costs of litigation.
       ``(h) Nonapplication of Claims Filing Requirements.--An 
     insurance company, health maintenance organization, self-
     insurance plan, managed care plan, or other health care plan 
     or program (under the Social Security Act or otherwise) may 
     not deny a claim for benefits submitted by the Service or by 
     an Indian Tribe or Tribal Organization based on the format in 
     which the claim is submitted if such format complies with the 
     format required for submission of claims under title XVIII of 
     the Social Security Act or recognized under section 1175 of 
     such Act.
       ``(i) Application to Urban Indian Organizations.--The 
     previous provisions of this section shall apply to urban 
     Indian organizations with respect to populations served by 
     such Organizations in the same manner they apply to Indian 
     Tribes and Tribal Organizations with respect to populations 
     served by such Indian Tribes and Tribal Organizations.
       ``(j) Statute of Limitations.--The provisions of section 
     2415 of title 28, United States Code, shall apply to all 
     actions commenced under this section, and the references 
     therein to the United States are deemed to include Indian 
     Tribes, Tribal Organizations, and urban Indian organizations.
       ``(k) Savings.--Nothing in this section shall be construed 
     to limit any right of recovery available to the United 
     States, an Indian Tribe, or Tribal Organization under the 
     provisions of any applicable, Federal, State, or Tribal law, 
     including medical lien laws.

     ``SEC. 404. CREDITING OF REIMBURSEMENTS.

       ``(a) Retention of Amounts for Use by Program.--Except as 
     provided in section 202(f) (relating to the Catastrophic 
     Health Emergency Fund) and section 806 (relating to health 
     services for ineligible persons), all reimbursements received 
     or recovered, including under section 806, by reason of the 
     provision of health services by the Service, by an Indian 
     Tribe or Tribal Organization, or by an urban Indian 
     organization, shall be credited to the Service, such Indian 
     Tribe or Tribal Organization, or such urban Indian 
     organization, respectively, and may be used as provided in 
     section 401. In the case of such a service provided by or 
     through a Service Unit, such amounts shall be credited to 
     such unit and used for such purposes.
       ``(b) No Offset of Amounts.--The Service may not offset or 
     limit any amount obligated to any Service Unit or entity 
     receiving funding from the Service because of the receipt of 
     reimbursements under subsection (a).

     ``SEC. 405. PURCHASING HEALTH CARE COVERAGE.

       ``(a) Purchasing Coverage.--
       ``(1) In general.--Insofar as amounts are made available 
     under law (including a provision of the Social Security Act, 
     the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450 et seq.), or other law, other than under 
     section 402) to Indian Tribes, Tribal Organizations, and 
     urban Indian organizations for health benefits for Service 
     beneficiaries, Indian Tribes, Tribal Organizations, and urban 
     Indian organizations may use such amounts to purchase health 
     benefits coverage that qualifies as creditable coverage under 
     section 2701(c)(1) of the Public Health Service Act for such 
     beneficiaries, including, subject to paragraph (2), through--
       ``(A) a tribally owned and operated health care plan;
       ``(B) a State or locally authorized or licensed health care 
     plan;
       ``(C) a health insurance provider or managed care 
     organization; or
       ``(D) a self-insured plan.
       ``(2) Exception.--The coverage provided under paragraph (1) 
     may not include coverage consisting of--
       ``(A) benefits provided under a health flexible spending 
     arrangement (as defined in section 106(c)(2) of the Internal 
     Revenue Code of 1986); or
       ``(B) a high deductible health plan (as defined in section 
     223(c)(2) of such Code), without regard to whether the plan 
     is purchased in conjunction with a health savings account (as 
     defined under section 223(d) of such Code).
       ``(3) Permitting purchase of coverage based on financial 
     need.--The purchase of coverage by an Indian Tribe, Tribal 
     Organization, or urban Indian organization under this 
     subsection may be based on the financial needs of 
     beneficiaries (as determined by the Indian Tribe or Tribes 
     being served based on a schedule of income levels developed 
     or implemented by such Indian Tribe or Tribes).
       ``(b) Expenses for Self-insured Plan.--In the case of a 
     self-insured plan under subsection (a)(4), the amounts may be 
     used for expenses of operating the plan, including 
     administration and insurance to limit the financial risks to 
     the entity offering the plan.
       ``(c) Construction.--Nothing in this section shall be 
     construed as affecting the use of any amounts not referred to 
     in subsection (a).

     ``SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

       ``(a) Authority.--
       ``(1) In general.--The Secretary may enter into (or expand) 
     arrangements for the sharing of medical facilities and 
     services between the Service, Indian Tribes, and Tribal 
     Organizations and the Department of Veterans Affairs and the 
     Department of Defense.
       ``(2) Consultation by secretary required.--The Secretary 
     may not finalize any arrangement between the Service and a 
     Department described in paragraph (1) without first 
     consulting with the Indian Tribes which will be significantly 
     affected by the arrangement.
       ``(b) Limitations.--The Secretary shall not take any action 
     under this section or under

[[Page 27416]]

     subchapter IV of chapter 81 of title 38, United States Code, 
     which would impair--
       ``(1) the priority access of any Indian to health care 
     services provided through the Service and the eligibility of 
     any Indian to receive health services through the Service;
       ``(2) the quality of health care services provided to any 
     Indian through the Service;
       ``(3) the priority access of any veteran to health care 
     services provided by the Department of Veterans Affairs;
       ``(4) the quality of health care services provided by the 
     Department of Veterans Affairs or the Department of Defense; 
     or
       ``(5) the eligibility of any Indian who is a veteran to 
     receive health services through the Department of Veterans 
     Affairs.
       ``(c) Reimbursement.--The Service, Indian Tribe, or Tribal 
     Organization shall be reimbursed by the Department of 
     Veterans Affairs or the Department of Defense (as the case 
     may be) where services are provided through the Service, an 
     Indian Tribe, or a Tribal Organization to beneficiaries 
     eligible for services from either such Department, 
     notwithstanding any other provision of law.
       ``(d) Construction.--Nothing in this section may be 
     construed as creating any right of a non-Indian veteran to 
     obtain health services from the Service.

     ``SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES.

       ``(a) Findings; Purpose.--
       ``(1) Findings.--Congress finds that--
       ``(A) collaborations between the Secretary and the 
     Secretary of Veterans Affairs regarding the treatment of 
     Indian veterans at facilities of the Service should be 
     encouraged to the maximum extent practicable; and
       ``(B) increased enrollment for services of the Department 
     of Veterans Affairs by veterans who are members of Indian 
     tribes should be encouraged to the maximum extent 
     practicable.
       ``(2) Purpose.--The purpose of this section is to reaffirm 
     the goals stated in the document entitled `Memorandum of 
     Understanding Between the VA/Veterans Health Administration 
     And HHS/Indian Health Service' and dated February 25, 2003 
     (relating to cooperation and resource sharing between the 
     Veterans Health Administration and Service).
       ``(b) Definitions.--In this section:
       ``(1) Eligible indian veteran.--The term `eligible Indian 
     veteran' means an Indian or Alaska Native veteran who 
     receives any medical service that is--
       ``(A) authorized under the laws administered by the 
     Secretary of Veterans Affairs; and
       ``(B) administered at a facility of the Service (including 
     a facility operated by an Indian tribe or tribal organization 
     through a contract or compact with the Service under the 
     Indian Self-Determination and Education Assistance Act (25 
     U.S.C. 450 et seq.)) pursuant to a local memorandum of 
     understanding.
       ``(2) Local memorandum of understanding.--The term `local 
     memorandum of understanding' means a memorandum of 
     understanding between the Secretary (or a designee, including 
     the director of any Area Office of the Service) and the 
     Secretary of Veterans Affairs (or a designee) to implement 
     the document entitled `Memorandum of Understanding Between 
     the VA/Veterans Health Administration And HHS/Indian Health 
     Service' and dated February 25, 2003 (relating to cooperation 
     and resource sharing between the Veterans Health 
     Administration and Indian Health Service).
       ``(c) Eligible Indian Veterans' Expenses.--
       ``(1) In general.--Notwithstanding any other provision of 
     law, the Secretary shall provide for veteran-related expenses 
     incurred by eligible Indian veterans as described in 
     subsection (b)(1)(B).
       ``(2) Method of payment.--The Secretary shall establish 
     such guidelines as the Secretary determines to be appropriate 
     regarding the method of payments to the Secretary of Veterans 
     Affairs under paragraph (1).
       ``(d) Tribal Approval of Memoranda.--In negotiating a local 
     memorandum of understanding with the Secretary of Veterans 
     Affairs regarding the provision of services to eligible 
     Indian veterans, the Secretary shall consult with each Indian 
     tribe that would be affected by the local memorandum of 
     understanding.
       ``(e) Funding.--
       ``(1) Treatment.--Expenses incurred by the Secretary in 
     carrying out subsection (c)(1) shall not be considered to be 
     Contract Health Service expenses.
       ``(2) Use of funds.--Of funds made available to the 
     Secretary in appropriations Acts for the Service (excluding 
     funds made available for facilities, Contract Health 
     Services, or contract support costs), the Secretary shall use 
     such sums as are necessary to carry out this section.

     ``SEC. 408. PAYOR OF LAST RESORT.

       ``Indian Health Programs and health care programs operated 
     by Urban Indian Organizations shall be the payor of last 
     resort for services provided to persons eligible for services 
     from Indian Health Programs and Urban Indian Organizations, 
     notwithstanding any Federal, State, or local law to the 
     contrary.

     ``SEC. 409. CONSULTATION.

       ``For provisions related to consultation with 
     representatives of Indian Health Programs and urban Indian 
     organizations with respect to the health care programs 
     established under titles XVIII, XIX, and XXI of the Social 
     Security Act, see section 1139(d) of the Social Security Act 
     (42 U.S.C. 1320b-9(d)).

     ``SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM 
                   (SCHIP).

       ``For provisions relating to--
       ``(1) outreach to families of Indian children likely to be 
     eligible for child health assistance under the State 
     children's health insurance program established under title 
     XXI of the Social Security Act, see sections 2105(c)(2)(C) 
     and 1139(a) of such Act (42 U.S.C. 1397ee(c)(2), 1320b-9); 
     and
       ``(2) ensuring that child health assistance is provided 
     under such program to targeted low-income children who are 
     Indians and that payments are made under such program to 
     Indian Health Programs and urban Indian organizations 
     operating in the State that provide such assistance, see 
     sections 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 
     U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)).

     ``SEC. 411. PREMIUM AND COST SHARING PROTECTIONS AND 
                   ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND 
                   SCHIP AND PROTECTION OF CERTAIN INDIAN PROPERTY 
                   FROM MEDICAID ESTATE RECOVERY.

       ``For provisions relating to--
       ``(1) premiums or cost sharing protections for Indians 
     furnished items or services directly by Indian Health 
     Programs or through referral under the contract health 
     service under the Medicaid program established under title 
     XIX of the Social Security Act, see sections 1916(j) and 
     1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o(j), 
     1396o-1(a)(1));
       ``(2) rules regarding the treatment of certain property for 
     purposes of determining eligibility under such programs, see 
     sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C. 
     1396a(e)(13), 1397gg(e)(1)(B)); and
       ``(3) the protection of certain property from estate 
     recovery provisions under the Medicaid program, see section 
     1917(b)(3)(B) of such Act (42 U.S.C. 1396p(b)(3)(B)).

     ``SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.

       ``For provisions relating to the treatment of Indians 
     enrolled in a managed care entity under the Medicaid program 
     under title XIX of the Social Security Act and Indian Health 
     Programs and urban Indian organizations that are providers of 
     items or services to such Indian enrollees, see sections 
     1932(h) and 2107(e)(1)(H) of the Social Security Act (42 
     U.S.C. 1396u-2(h), 1397gg(e)(1)(H)).

     ``SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

       ``(a) Study.--The Secretary shall conduct a study to 
     determine the feasibility of treating the Navajo Nation as a 
     State for the purposes of title XIX of the Social Security 
     Act, to provide services to Indians living within the 
     boundaries of the Navajo Nation through an entity established 
     having the same authority and performing the same functions 
     as single-State Medicaid agencies responsible for the 
     administration of the State plan under title XIX of the 
     Social Security Act.
       ``(b) Considerations.--In conducting the study, the 
     Secretary shall consider the feasibility of--
       ``(1) assigning and paying all expenditures for the 
     provision of services and related administration funds, under 
     title XIX of the Social Security Act, to Indians living 
     within the boundaries of the Navajo Nation that are currently 
     paid to or would otherwise be paid to the State of Arizona, 
     New Mexico, or Utah;
       ``(2) providing assistance to the Navajo Nation in the 
     development and implementation of such entity for the 
     administration, eligibility, payment, and delivery of medical 
     assistance under title XIX of the Social Security Act;
       ``(3) providing an appropriate level of matching funds for 
     Federal medical assistance with respect to amounts such 
     entity expends for medical assistance for services and 
     related administrative costs; and
       ``(4) authorizing the Secretary, at the option of the 
     Navajo Nation, to treat the Navajo Nation as a State for the 
     purposes of title XIX of the Social Security Act (relating to 
     the State children's health insurance program) under terms 
     equivalent to those described in paragraphs (2) through (4).
       ``(c) Report.--Not later than 3 years after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary shall submit to the 
     Committee on Indian Affairs and Committee on Finance of the 
     Senate and the Committee on Natural Resources and Committee 
     on Energy and Commerce of the House of Representatives a 
     report that includes--
       ``(1) the results of the study under this section;
       ``(2) a summary of any consultation that occurred between 
     the Secretary and the Navajo Nation, other Indian Tribes, the 
     States of Arizona, New Mexico, and Utah, counties which 
     include Navajo Lands, and other interested parties, in 
     conducting this study;
       ``(3) projected costs or savings associated with 
     establishment of such entity, and any estimated impact on 
     services provided as described in this section in relation to 
     probable costs or savings; and
       ``(4) legislative actions that would be required to 
     authorize the establishment of such entity if such entity is 
     determined by the Secretary to be feasible.

[[Page 27417]]



     ``SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS.

       ``The previous provisions of this title shall not apply to 
     the provision of excepted benefits described in paragraph 
     (1)(A) or (3) of section 2791(c) of the Public Health Service 
     Act (42 U.S.C. 300gg-91(c)).

     ``SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

       ``There are authorized to be appropriated such sums as may 
     be necessary to carry out this title.

              ``TITLE V--HEALTH SERVICES FOR URBAN INDIANS

     ``SEC. 501. PURPOSE.

       ``The purpose of this title is to establish and maintain 
     programs in Urban Centers to make health services more 
     accessible and available to Urban Indians.

     ``SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN 
                   ORGANIZATIONS.

       ``Under authority of the Act of November 2, 1921 (25 U.S.C. 
     13) (commonly known as the `Snyder Act'), the Secretary, 
     acting through the Service, shall enter into contracts with, 
     or make grants to, urban Indian organizations to assist such 
     organizations in the establishment and administration, within 
     Urban Centers, of programs which meet the requirements set 
     forth in this title. Subject to section 506, the Secretary, 
     acting through the Service, shall include such conditions as 
     the Secretary considers necessary to effect the purpose of 
     this title in any contract into which the Secretary enters 
     with, or in any grant the Secretary makes to, any urban 
     Indian organization pursuant to this title.

     ``SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH 
                   CARE AND REFERRAL SERVICES.

       ``(a) Requirements for Grants and Contracts.--Under 
     authority of the Act of November 2, 1921 (25 U.S.C. 13) 
     (commonly known as the `Snyder Act'), the Secretary, acting 
     through the Service, shall enter into contracts with, and 
     make grants to, urban Indian organizations for the provision 
     of health care and referral services for Urban Indians. Any 
     such contract or grant shall include requirements that the 
     urban Indian organization successfully undertake to--
       ``(1) estimate the population of Urban Indians residing in 
     the Urban Center or centers that the organization proposes to 
     serve who are or could be recipients of health care or 
     referral services;
       ``(2) estimate the current health status of Urban Indians 
     residing in such Urban Center or centers;
       ``(3) estimate the current health care needs of Urban 
     Indians residing in such Urban Center or centers;
       ``(4) provide basic health education, including health 
     promotion and disease prevention education, to Urban Indians;
       ``(5) make recommendations to the Secretary and Federal, 
     State, local, and other resource agencies on methods of 
     improving health service programs to meet the needs of Urban 
     Indians; and
       ``(6) where necessary, provide, or enter into contracts for 
     the provision of, health care services for Urban Indians.
       ``(b) Criteria.--The Secretary, acting through the Service, 
     shall, by regulation, prescribe the criteria for selecting 
     urban Indian organizations to enter into contracts or receive 
     grants under this section. Such criteria shall, among other 
     factors, include--
       ``(1) the extent of unmet health care needs of Urban 
     Indians in the Urban Center or centers involved;
       ``(2) the size of the urban Indian population in the Urban 
     Center or centers involved;
       ``(3) the extent, if any, to which the activities set forth 
     in subsection (a) would duplicate any project funded under 
     this title, or under any current public health service 
     project funded in a manner other than pursuant to this title;
       ``(4) the capability of an urban Indian organization to 
     perform the activities set forth in subsection (a) and to 
     enter into a contract with the Secretary or to meet the 
     requirements for receiving a grant under this section;
       ``(5) the satisfactory performance and successful 
     completion by an urban Indian organization of other contracts 
     with the Secretary under this title;
       ``(6) the appropriateness and likely effectiveness of 
     conducting the activities set forth in subsection (a) in an 
     Urban Center or centers; and
       ``(7) the extent of existing or likely future participation 
     in the activities set forth in subsection (a) by appropriate 
     health and health-related Federal, State, local, and other 
     agencies.
       ``(c) Access to Health Promotion and Disease Prevention 
     Programs.--The Secretary, acting through the Service, shall 
     facilitate access to or provide health promotion and disease 
     prevention services for Urban Indians through grants made to 
     urban Indian organizations administering contracts entered 
     into or receiving grants under subsection (a).
       ``(d) Immunization Services.--
       ``(1) Access or services provided.--The Secretary, acting 
     through the Service, shall facilitate access to, or provide, 
     immunization services for Urban Indians through grants made 
     to urban Indian organizations administering contracts entered 
     into or receiving grants under this section.
       ``(2) Definition.--For purposes of this subsection, the 
     term `immunization services' means services to provide 
     without charge immunizations against vaccine-preventable 
     diseases.
       ``(e) Behavioral Health Services.--
       ``(1) Access or services provided.--The Secretary, acting 
     through the Service, shall facilitate access to, or provide, 
     behavioral health services for Urban Indians through grants 
     made to urban Indian organizations administering contracts 
     entered into or receiving grants under subsection (a).
       ``(2) Assessment required.--Except as provided by paragraph 
     (3)(A), a grant may not be made under this subsection to an 
     urban Indian organization until that organization has 
     prepared, and the Service has approved, an assessment of the 
     following:
       ``(A) The behavioral health needs of the urban Indian 
     population concerned.
       ``(B) The behavioral health services and other related 
     resources available to that population.
       ``(C) The barriers to obtaining those services and 
     resources.
       ``(D) The needs that are unmet by such services and 
     resources.
       ``(3) Purposes of grants.--Grants may be made under this 
     subsection for the following:
       ``(A) To prepare assessments required under paragraph (2).
       ``(B) To provide outreach, educational, and referral 
     services to Urban Indians regarding the availability of 
     direct behavioral health services, to educate Urban Indians 
     about behavioral health issues and services, and effect 
     coordination with existing behavioral health providers in 
     order to improve services to Urban Indians.
       ``(C) To provide outpatient behavioral health services to 
     Urban Indians, including the identification and assessment of 
     illness, therapeutic treatments, case management, support 
     groups, family treatment, and other treatment.
       ``(D) To develop innovative behavioral health service 
     delivery models which incorporate Indian cultural support 
     systems and resources.
       ``(f) Prevention of Child Abuse.--
       ``(1) Access or services provided.--The Secretary, acting 
     through the Service, shall facilitate access to or provide 
     services for Urban Indians through grants to urban Indian 
     organizations administering contracts entered into or 
     receiving grants under subsection (a) to prevent and treat 
     child abuse (including sexual abuse) among Urban Indians.
       ``(2) Evaluation required.--Except as provided by paragraph 
     (3)(A), a grant may not be made under this subsection to an 
     urban Indian organization until that organization has 
     prepared, and the Service has approved, an assessment that 
     documents the prevalence of child abuse in the urban Indian 
     population concerned and specifies the services and programs 
     (which may not duplicate existing services and programs) for 
     which the grant is requested.
       ``(3) Purposes of grants.--Grants may be made under this 
     subsection for the following:
       ``(A) To prepare assessments required under paragraph (2).
       ``(B) For the development of prevention, training, and 
     education programs for Urban Indians, including child 
     education, parent education, provider training on 
     identification and intervention, education on reporting 
     requirements, prevention campaigns, and establishing service 
     networks of all those involved in Indian child protection.
       ``(C) To provide direct outpatient treatment services 
     (including individual treatment, family treatment, group 
     therapy, and support groups) to Urban Indians who are child 
     victims of abuse (including sexual abuse) or adult survivors 
     of child sexual abuse, to the families of such child victims, 
     and to urban Indian perpetrators of child abuse (including 
     sexual abuse).
       ``(4) Considerations when making grants.--In making grants 
     to carry out this subsection, the Secretary shall take into 
     consideration--
       ``(A) the support for the urban Indian organization 
     demonstrated by the child protection authorities in the area, 
     including committees or other services funded under the 
     Indian Child Welfare Act of 1978 (25 U.S.C. 1901 et seq.), if 
     any;
       ``(B) the capability and expertise demonstrated by the 
     urban Indian organization to address the complex problem of 
     child sexual abuse in the community; and
       ``(C) the assessment required under paragraph (2).
       ``(g) Other Grants.--The Secretary, acting through the 
     Service, may enter into a contract with or make grants to an 
     urban Indian organization that provides or arranges for the 
     provision of health care services (through satellite 
     facilities, provider networks, or otherwise) to Urban Indians 
     in more than 1 Urban Center.

     ``SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES 
                   OF SUPPLY.

       ``(a) In General.--The Secretary may permit an urban Indian 
     organization that has entered into a contract or received a 
     grant pursuant to this title, in carrying out such contract 
     or grant, to use existing facilities and all equipment 
     therein or pertaining thereto and other personal property 
     owned by the Federal Government within the Secretary's 
     jurisdiction under such terms and conditions as may be agreed 
     upon for their use and maintenance.

[[Page 27418]]

       ``(b) Donations.--Subject to subsection (d), the Secretary 
     may donate to an urban Indian organization that has entered 
     into a contract or received a grant pursuant to this title 
     any personal or real property determined to be excess to the 
     needs of the Indian Health Service or the General Services 
     Administration for the purposes of carrying out the contract 
     or grant.
       ``(c) Acquisition of Property.--The Secretary may acquire 
     excess or surplus government personal or real property for 
     donation, subject to subsection (d) to an urban Indian 
     organization that has entered into a contract or received a 
     grant pursuant to this title if the Secretary determines that 
     the property is appropriate for use by the urban Indian 
     organization for a purpose for which a contract or grant is 
     authorized under this title.
       ``(d) Priority.--In the event that the Secretary receives a 
     request for a specific item of personal or real property 
     described in subsections (b) or (c) from an urban Indian 
     organization and from an Indian Tribe or Tribal Organization, 
     the Secretary shall give priority to the request for donation 
     to the Indian Tribe or Tribal Organization if the Secretary 
     receives the request from the Indian Tribe or Tribal 
     Organization before the date the Secretary transfers title to 
     the property or, if earlier, the date the Secretary transfers 
     the property physically, to the urban Indian organization.
       ``(e) Executive Agency Status.--For purposes of section 
     201(a) of the Federal Property and Administrative Services 
     Act of 1949 (40 U.S.C. 481(a)) (relating to Federal sources 
     of supply), an urban Indian organization that has entered 
     into a contract or received a grant pursuant to this title 
     may be deemed to be an executive agency when carrying out 
     such contract or grant.

     ``SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINATION OF 
                   UNMET HEALTH CARE NEEDS.

       ``(a) Grants and Contracts Authorized.--Under authority of 
     the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as 
     the `Snyder Act'), the Secretary, acting through the Service, 
     may enter into contracts with or make grants to urban Indian 
     organizations situated in Urban Centers for which contracts 
     have not been entered into or grants have not been made under 
     section 503.
       ``(b) Purpose.--The purpose of a contract or grant made 
     under this section shall be the determination of the matters 
     described in subsection (c)(1) in order to assist the 
     Secretary in assessing the health status and health care 
     needs of Urban Indians in the Urban Center involved and 
     determining whether the Secretary should enter into a 
     contract or make a grant under section 503 with respect to 
     the urban Indian organization which the Secretary has entered 
     into a contract with, or made a grant to, under this section.
       ``(c) Grant and Contract Requirements.--Any contract 
     entered into, or grant made, by the Secretary under this 
     section shall include requirements that--
       ``(1) the urban Indian organization successfully undertakes 
     to--
       ``(A) document the health care status and unmet health care 
     needs of urban Indians in the Urban Center involved; and
       ``(B) with respect to urban Indians in the Urban Center 
     involved, determine the matters described in paragraphs (2), 
     (3), (4), and (7) of section 503(b); and
       ``(2) the urban Indian organization complete performance of 
     the contract, or carry out the requirements of the grant, 
     within 1 year after the date on which the Secretary and such 
     organization enter into such contract, or within 1 year after 
     such organization receives such grant, whichever is 
     applicable.
       ``(d) No Renewals.--The Secretary may not renew any 
     contract entered into or grant made under this section.

     ``SEC. 506. EVALUATIONS; RENEWALS.

       ``(a) Procedures for Evaluations.--The Secretary, acting 
     through the Service, shall develop procedures to evaluate 
     compliance with grant requirements and compliance with and 
     performance of contracts entered into by urban Indian 
     organizations under this title. Such procedures shall include 
     provisions for carrying out the requirements of this section.
       ``(b) Evaluations.--The Secretary, acting through the 
     Service, shall evaluate the compliance of each Urban Indian 
     Organization which has entered into a contract or received a 
     grant under section 503 with the terms of such contract or 
     grant. For purposes of this evaluation, the Secretary shall--
       ``(1) acting through the Service, conduct an annual onsite 
     evaluation of the organization; or
       ``(2) accept in lieu of such onsite evaluation evidence of 
     the organization's provisional or full accreditation by a 
     private independent entity recognized by the Secretary for 
     purposes of conducting quality reviews of providers 
     participating in the Medicare program under title XVIII of 
     the Social Security Act.
       ``(c) Noncompliance; Unsatisfactory Performance.--If, as a 
     result of the evaluations conducted under this section, the 
     Secretary determines that an urban Indian organization has 
     not complied with the requirements of a grant or complied 
     with or satisfactorily performed a contract under section 
     503, the Secretary shall, prior to renewing such contract or 
     grant, attempt to resolve with the organization the areas of 
     noncompliance or unsatisfactory performance and modify the 
     contract or grant to prevent future occurrences of 
     noncompliance or unsatisfactory performance. If the Secretary 
     determines that the noncompliance or unsatisfactory 
     performance cannot be resolved and prevented in the future, 
     the Secretary shall not renew the contract or grant with the 
     organization and is authorized to enter into a contract or 
     make a grant under section 503 with another urban Indian 
     organization which is situated in the same Urban Center as 
     the urban Indian organization whose contract or grant is not 
     renewed under this section.
       ``(d) Considerations for Renewals.--In determining whether 
     to renew a contract or grant with an urban Indian 
     organization under section 503 which has completed 
     performance of a contract or grant under section 504, the 
     Secretary shall review the records of the urban Indian 
     organization, the reports submitted under section 507, and 
     shall consider the results of the onsite evaluations or 
     accreditations under subsection (b).

     ``SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS.

       ``(a) Procurement.--Contracts with urban Indian 
     organizations entered into pursuant to this title shall be in 
     accordance with all Federal contracting laws and regulations 
     relating to procurement except that in the discretion of the 
     Secretary, such contracts may be negotiated without 
     advertising and need not conform to the provisions of 
     sections 1304 and 3131 through 3133 of title 40, United 
     States Code.
       ``(b) Payments Under Contracts or Grants.--
       ``(1) In general.--Payments under any contracts or grants 
     pursuant to this title, notwithstanding any term or condition 
     of such contract or grant--
       ``(A) may be made in a single advance payment by the 
     Secretary to the urban Indian organization by no later than 
     the end of the first 30 days of the funding period with 
     respect to which the payments apply, unless the Secretary 
     determines through an evaluation under section 505 that the 
     organization is not capable of administering such a single 
     advance payment; and
       ``(B) if any portion thereof is unexpended by the urban 
     Indian organization during the funding period with respect to 
     which the payments initially apply, shall be carried forward 
     for expenditure with respect to allowable or reimbursable 
     costs incurred by the organization during 1 or more 
     subsequent funding periods without additional justification 
     or documentation by the organization as a condition of 
     carrying forward the availability for expenditure of such 
     funds.
       ``(2) Semiannual and quarterly payments and 
     reimbursements.--If the Secretary determines under paragraph 
     (1)(A) that an urban Indian organization is not capable of 
     administering an entire single advance payment, on request of 
     the urban Indian organization, the payments may be made--
       ``(A) in semiannual or quarterly payments by not later than 
     30 days after the date on which the funding period with 
     respect to which the payments apply begins; or
       ``(B) by way of reimbursement.
       ``(c) Revision or Amendment of Contracts.--Notwithstanding 
     any provision of law to the contrary, the Secretary may, at 
     the request and consent of an urban Indian organization, 
     revise or amend any contract entered into by the Secretary 
     with such organization under this title as necessary to carry 
     out the purposes of this title.
       ``(d) Fair and Uniform Services and Assistance.--Contracts 
     with or grants to urban Indian organizations and regulations 
     adopted pursuant to this title shall include provisions to 
     assure the fair and uniform provision to urban Indians of 
     services and assistance under such contracts or grants by 
     such organizations.

     ``SEC. 508. REPORTS AND RECORDS.

       ``(a) Reports.--
       ``(1) In general.--For each fiscal year during which an 
     urban Indian organization receives or expends funds pursuant 
     to a contract entered into or a grant received pursuant to 
     this title, such urban Indian organization shall submit to 
     the Secretary not more frequently than every 6 months, a 
     report that includes the following:
       ``(A) In the case of a contract or grant under section 503, 
     recommendations pursuant to section 503(a)(5).
       ``(B) Information on activities conducted by the 
     organization pursuant to the contract or grant.
       ``(C) An accounting of the amounts and purpose for which 
     Federal funds were expended.
       ``(D) A minimum set of data, using uniformly defined 
     elements, as specified by the Secretary after consultation 
     with urban Indian organizations.
       ``(2) Health status and services.--
       ``(A) In general.--Not later than 18 months after the date 
     of enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary, acting through the 
     Service, shall submit to Congress a report evaluating--
       ``(i) the health status of urban Indians;

[[Page 27419]]

       ``(ii) the services provided to Indians pursuant to this 
     title; and
       ``(iii) areas of unmet needs in the delivery of health 
     services to urban Indians.
       ``(B) Consultation and contracts.--In preparing the report 
     under paragraph (1), the Secretary--
       ``(i) shall consult with urban Indian organizations; and
       ``(ii) may enter into a contract with a national 
     organization representing urban Indian organizations to 
     conduct any aspect of the report.
       ``(b) Audit.--The reports and records of the urban Indian 
     organization with respect to a contract or grant under this 
     title shall be subject to audit by the Secretary and the 
     Comptroller General of the United States.
       ``(c) Costs of Audits.--The Secretary shall allow as a cost 
     of any contract or grant entered into or awarded under 
     section 502 or 503 the cost of an annual independent 
     financial audit conducted by--
       ``(1) a certified public accountant; or
       ``(2) a certified public accounting firm qualified to 
     conduct Federal compliance audits.

     ``SEC. 509. LIMITATION ON CONTRACT AUTHORITY.

       ``The authority of the Secretary to enter into contracts or 
     to award grants under this title shall be to the extent, and 
     in an amount, provided for in appropriation Acts.

     ``SEC. 510. FACILITIES.

       ``(a) Grants.--The Secretary, acting through the Service, 
     may make grants to contractors or grant recipients under this 
     title for the lease, purchase, renovation, construction, or 
     expansion of facilities, including leased facilities, in 
     order to assist such contractors or grant recipients in 
     complying with applicable licensure or certification 
     requirements.
       ``(b) Loan Fund Study.--The Secretary, acting through the 
     Service, may carry out a study to determine the feasibility 
     of establishing a loan fund to provide to urban Indian 
     organizations direct loans or guarantees for loans for the 
     construction of health care facilities in a manner consistent 
     with section 309, including by submitting a report in 
     accordance with subsection (c) of that section.

     ``SEC. 511. DIVISION OF URBAN INDIAN HEALTH.

       ``There is established within the Service a Division of 
     Urban Indian Health, which shall be responsible for--
       ``(1) carrying out the provisions of this title;
       ``(2) providing central oversight of the programs and 
     services authorized under this title; and
       ``(3) providing technical assistance to urban Indian 
     organizations.

     ``SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED 
                   SERVICES.

       ``(a) Grants Authorized.--The Secretary, acting through the 
     Service, may make grants for the provision of health-related 
     services in prevention of, treatment of, rehabilitation of, 
     or school- and community-based education regarding, alcohol 
     and substance abuse in Urban Centers to those urban Indian 
     organizations with which the Secretary has entered into a 
     contract under this title or under section 201.
       ``(b) Goals.--Each grant made pursuant to subsection (a) 
     shall set forth the goals to be accomplished pursuant to the 
     grant. The goals shall be specific to each grant as agreed to 
     between the Secretary and the grantee.
       ``(c) Criteria.--The Secretary shall establish criteria for 
     the grants made under subsection (a), including criteria 
     relating to the following:
       ``(1) The size of the urban Indian population.
       ``(2) Capability of the organization to adequately perform 
     the activities required under the grant.
       ``(3) Satisfactory performance standards for the 
     organization in meeting the goals set forth in such grant. 
     The standards shall be negotiated and agreed to between the 
     Secretary and the grantee on a grant-by-grant basis.
       ``(4) Identification of the need for services.
       ``(d) Allocation of Grants.--The Secretary shall develop a 
     methodology for allocating grants made pursuant to this 
     section based on the criteria established pursuant to 
     subsection (c).
       ``(e) Grants Subject to Criteria.--Any grant received by an 
     urban Indian organization under this Act for substance abuse 
     prevention, treatment, and rehabilitation shall be subject to 
     the criteria set forth in subsection (c).

     ``SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

       ``Notwithstanding any other provision of law, the Tulsa 
     Clinic and Oklahoma City Clinic demonstration projects 
     shall--
       ``(1) be permanent programs within the Service's direct 
     care program;
       ``(2) continue to be treated as Service Units and Operating 
     Units in the allocation of resources and coordination of 
     care; and
       ``(3) continue to meet the requirements and definitions of 
     an urban Indian organization in this Act, and shall not be 
     subject to the provisions of the Indian Self-Determination 
     and Education Assistance Act (25 U.S.C. 450 et seq.).

     ``SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS.

       ``(a) Grants and Contracts.--The Secretary, through the 
     Division of Urban Indian Health, shall make grants or enter 
     into contracts with urban Indian organizations, to take 
     effect not later than September 30, 2010, for the 
     administration of urban Indian alcohol programs that were 
     originally established under the National Institute on 
     Alcoholism and Alcohol Abuse (hereafter in this section 
     referred to as `NIAAA') and transferred to the Service.
       ``(b) Use of Funds.--Grants provided or contracts entered 
     into under this section shall be used to provide support for 
     the continuation of alcohol prevention and treatment services 
     for urban Indian populations and such other objectives as are 
     agreed upon between the Service and a recipient of a grant or 
     contract under this section.
       ``(c) Eligibility.--Urban Indian organizations that operate 
     Indian alcohol programs originally funded under the NIAAA and 
     subsequently transferred to the Service are eligible for 
     grants or contracts under this section.
       ``(d) Report.--The Secretary shall evaluate and report to 
     Congress on the activities of programs funded under this 
     section not less than every 5 years.

     ``SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZATIONS.

       ``(a) In General.--The Secretary shall ensure that the 
     Service confers or conferences, to the greatest extent 
     practicable, with Urban Indian Organizations.
       ``(b) Definition of Confer; Conference.--In this section, 
     the terms `confer' and `conference' mean an open and free 
     exchange of information and opinions that--
       ``(1) leads to mutual understanding and comprehension; and
       ``(2) emphasizes trust, respect, and shared responsibility.

     ``SEC. 516. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

       ``(a) Construction and Operation.--
       ``(1) In general.--The Secretary, acting through the 
     Service, through grant or contract, shall fund the 
     construction and operation of at least 1 residential 
     treatment center in each Service Area that meets the 
     eligibility requirements set forth in subsection (b) to 
     demonstrate the provision of alcohol and substance abuse 
     treatment services to Urban Indian youth in a culturally 
     competent residential setting.
       ``(2) Treatment.--Each residential treatment center 
     described in paragraph (1) shall be in addition to any 
     facilities constructed under section 707(b).
       ``(b) Eligibility Requirements.--To be eligible to obtain a 
     facility under subsection (a)(1), a Service Area shall meet 
     the following requirements:
       ``(1) There is an Urban Indian Organization in the Service 
     Area.
       ``(2) There reside in the Service Area Urban Indian youth 
     with need for alcohol and substance abuse treatment services 
     in a residential setting.
       ``(3) There is a significant shortage of culturally 
     competent residential treatment services for Urban Indian 
     youth in the Service Area.

     ``SEC. 517. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND 
                   CONTROL.

       ``(a) Grants Authorized.--The Secretary may make grants to 
     those urban Indian organizations that have entered into a 
     contract or have received a grant under this title for the 
     provision of services for the prevention and treatment of, 
     and control of the complications resulting from, diabetes 
     among urban Indians.
       ``(b) Goals.--Each grant made pursuant to subsection (a) 
     shall set forth the goals to be accomplished under the grant. 
     The goals shall be specific to each grant as agreed to 
     between the Secretary and the grantee.
       ``(c) Establishment of Criteria.--The Secretary shall 
     establish criteria for the grants made under subsection (a) 
     relating to--
       ``(1) the size and location of the urban Indian population 
     to be served;
       ``(2) the need for prevention of and treatment of, and 
     control of the complications resulting from, diabetes among 
     the urban Indian population to be served;
       ``(3) performance standards for the organization in meeting 
     the goals set forth in such grant that are negotiated and 
     agreed to by the Secretary and the grantee;
       ``(4) the capability of the organization to adequately 
     perform the activities required under the grant; and
       ``(5) the willingness of the organization to collaborate 
     with the registry, if any, established by the Secretary under 
     section 203(e)(1)(B) in the Area Office of the Service in 
     which the organization is located.
       ``(d) Funds Subject to Criteria.--Any funds received by an 
     urban Indian organization under this Act for the prevention, 
     treatment, and control of diabetes among urban Indians shall 
     be subject to the criteria developed by the Secretary under 
     subsection (c).

     ``SEC. 518. COMMUNITY HEALTH REPRESENTATIVES.

       ``The Secretary, acting through the Service, may enter into 
     contracts with, and make grants to, urban Indian 
     organizations for the employment of Indians trained as health 
     service providers through the Community Health 
     Representatives Program under section 109 in the provision of 
     health care,

[[Page 27420]]

     health promotion, and disease prevention services to urban 
     Indians.

     ``SEC. 519. EFFECTIVE DATE.

       ``The amendments made by the Indian Health Care Improvement 
     Act Amendments of 2009 to this title shall take effect 
     beginning on the date of enactment of that Act, regardless of 
     whether the Secretary has promulgated regulations 
     implementing such amendments.

     ``SEC. 520. ELIGIBILITY FOR SERVICES.

       ``Urban Indians shall be eligible for, and the ultimate 
     beneficiaries of, health care or referral services provided 
     pursuant to this title.

     ``SEC. 521. AUTHORIZATION OF APPROPRIATIONS.

       ``(a) In General.--There are authorized to be appropriated 
     such sums as may be necessary to carry out this title.
       ``(b) Urban Indian Organizations.--The Secretary, acting 
     through the Service, is authorized to establish programs, 
     including programs for the awarding of grants, for urban 
     Indian organizations that are identical to any programs 
     established pursuant to section 126 (behavioral health 
     training), section 209 (school health education), section 211 
     (prevention of communicable diseases), section 701 
     (behavioral health prevention and treatment services), and 
     section 707(g) (multidrug abuse program).

     ``SEC. 522. HEALTH INFORMATION TECHNOLOGY.

       ``The Secretary, acting through the Service, may make 
     grants to urban Indian organizations under this title for the 
     development, adoption, and implementation of health 
     information technology (as defined in section 3000(5) of the 
     American Recovery and Reinvestment Act), telemedicine 
     services development, and related infrastructure.

                ``TITLE VI--ORGANIZATIONAL IMPROVEMENTS

     ``SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN 
                   AGENCY OF THE PUBLIC HEALTH SERVICE.

       ``(a) Establishment.--
       ``(1) In general.--In order to more effectively and 
     efficiently carry out the responsibilities, authorities, and 
     functions of the United States to provide health care 
     services to Indians and Indian Tribes, as are or may be 
     hereafter provided by Federal statute or treaties, there is 
     established within the Public Health Service of the 
     Department the Indian Health Service.
       ``(2) Assistant secretary of indian health.--The Service 
     shall be administered by an Assistant Secretary of Indian 
     Health, who shall be appointed by the President, by and with 
     the advice and consent of the Senate. The Assistant Secretary 
     shall report to the Secretary. Effective with respect to an 
     individual appointed by the President, by and with the advice 
     and consent of the Senate, after January 1, 2010, the term of 
     service of the Assistant Secretary shall be 4 years. An 
     Assistant Secretary may serve more than 1 term.
       ``(3) Incumbent.--The individual serving in the position of 
     Director of the Service on the day before the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009 shall serve as Assistant Secretary.
       ``(4) Advocacy and consultation.--The position of Assistant 
     Secretary is established to, in a manner consistent with the 
     government-to-government relationship between the United 
     States and Indian Tribes--
       ``(A) facilitate advocacy for the development of 
     appropriate Indian health policy; and
       ``(B) promote consultation on matters relating to Indian 
     health.
       ``(b) Agency.--The Service shall be an agency within the 
     Public Health Service of the Department, and shall not be an 
     office, component, or unit of any other agency of the 
     Department.
       ``(c) Duties.--The Assistant Secretary shall--
       ``(1) perform all functions that were, on the day before 
     the date of enactment of the Indian Health Care Improvement 
     Act Amendments of 2009, carried out by or under the direction 
     of the individual serving as Director of the Service on that 
     day;
       ``(2) perform all functions of the Secretary relating to 
     the maintenance and operation of hospital and health 
     facilities for Indians and the planning for, and provision 
     and utilization of, health services for Indians;
       ``(3) administer all health programs under which health 
     care is provided to Indians based upon their status as 
     Indians which are administered by the Secretary, including 
     programs under--
       ``(A) this Act;
       ``(B) the Act of November 2, 1921 (25 U.S.C. 13);
       ``(C) the Act of August 5, 1954 (42 U.S.C. 2001 et seq.);
       ``(D) the Act of August 16, 1957 (42 U.S.C. 2005 et seq.); 
     and
       ``(E) the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450 et seq.);
       ``(4) administer all scholarship and loan functions carried 
     out under title I;
       ``(5) report directly to the Secretary concerning all 
     policy- and budget-related matters affecting Indian health;
       ``(6) collaborate with the Assistant Secretary for Health 
     concerning appropriate matters of Indian health that affect 
     the agencies of the Public Health Service;
       ``(7) advise each Assistant Secretary of the Department 
     concerning matters of Indian health with respect to which 
     that Assistant Secretary has authority and responsibility;
       ``(8) advise the heads of other agencies and programs of 
     the Department concerning matters of Indian health with 
     respect to which those heads have authority and 
     responsibility;
       ``(9) coordinate the activities of the Department 
     concerning matters of Indian health; and
       ``(10) perform such other functions as the Secretary may 
     designate.
       ``(d) Authority.--
       ``(1) In general.--The Secretary, acting through the 
     Assistant Secretary, shall have the authority--
       ``(A) except to the extent provided for in paragraph (2), 
     to appoint and compensate employees for the Service in 
     accordance with title 5, United States Code;
       ``(B) to enter into contracts for the procurement of goods 
     and services to carry out the functions of the Service; and
       ``(C) to manage, expend, and obligate all funds 
     appropriated for the Service.
       ``(2) Personnel actions.--Notwithstanding any other 
     provision of law, the provisions of section 12 of the Act of 
     June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to 
     all personnel actions taken with respect to new positions 
     created within the Service as a result of its establishment 
     under subsection (a).
       ``(e) References.--Any reference to the Director of the 
     Indian Health Service in any other Federal law, Executive 
     order, rule, regulation, or delegation of authority, or in 
     any document of or relating to the Director of the Indian 
     Health Service, shall be deemed to refer to the Assistant 
     Secretary.

     ``SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

       ``(a) Establishment.--
       ``(1) In general.--The Secretary shall establish an 
     automated management information system for the Service.
       ``(2) Requirements of system.--The information system 
     established under paragraph (1) shall include--
       ``(A) a financial management system;
       ``(B) a patient care information system for each area 
     served by the Service;
       ``(C) privacy protections consistent with the regulations 
     promulgated under section 264(c) of the Health Insurance 
     Portability and Accountability Act of 1996 or, to the extent 
     consistent with such regulations, other Federal rules 
     applicable to privacy of automated management information 
     systems of a Federal agency;
       ``(D) a services-based cost accounting component that 
     provides estimates of the costs associated with the provision 
     of specific medical treatments or services in each Area 
     office of the Service;
       ``(E) an interface mechanism for patient billing and 
     accounts receivable system; and
       ``(F) a training component.
       ``(b) Provision of Systems to Tribes and Organizations.--
     The Secretary shall provide each Tribal Health Program 
     automated management information systems which--
       ``(1) meet the management information needs of such Tribal 
     Health Program with respect to the treatment by the Tribal 
     Health Program of patients of the Service; and
       ``(2) meet the management information needs of the Service.
       ``(c) Access to Records.--The Service shall provide access 
     of patients to their medical or health records which are held 
     by, or on behalf of, the Service in accordance with the 
     regulations promulgated under section 264(c) of the Health 
     Insurance Portability and Accountability Act of 1996 or, to 
     the extent consistent with such regulations, other Federal 
     rules applicable to access to health care records.
       ``(d) Authority To Enhance Information Technology.--The 
     Secretary, acting through the Assistant Secretary, shall have 
     the authority to enter into contracts, agreements, or joint 
     ventures with other Federal agencies, States, private and 
     nonprofit organizations, for the purpose of enhancing 
     information technology in Indian Health Programs and 
     facilities.

     ``SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

       ``There is authorized to be appropriated such sums as may 
     be necessary to carry out this title.

                ``TITLE VII--BEHAVIORAL HEALTH PROGRAMS

     ``SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT 
                   SERVICES.

       ``(a) Purposes.--The purposes of this section are as 
     follows:
       ``(1) To authorize and direct the Secretary, acting through 
     the Service, to develop a comprehensive behavioral health 
     prevention and treatment program which emphasizes 
     collaboration among alcohol and substance abuse, social 
     services, and mental health programs.
       ``(2) To provide information, direction, and guidance 
     relating to mental illness and dysfunction and self-
     destructive behavior, including child abuse and family 
     violence, to those Federal, tribal, State, and local agencies 
     responsible for programs in Indian communities in areas of 
     health care, education, social services, child and family 
     welfare, alcohol and substance abuse, law enforcement, and 
     judicial services.

[[Page 27421]]

       ``(3) To assist Indian Tribes to identify services and 
     resources available to address mental illness and 
     dysfunctional and self-destructive behavior.
       ``(4) To provide authority and opportunities for Indian 
     Tribes and Tribal Organizations to develop, implement, and 
     coordinate with community-based programs which include 
     identification, prevention, education, referral, and 
     treatment services, including through multidisciplinary 
     resource teams.
       ``(5) To ensure that Indians, as citizens of the United 
     States and of the States in which they reside, have the same 
     access to behavioral health services to which all citizens 
     have access.
       ``(6) To modify or supplement existing programs and 
     authorities in the areas identified in paragraph (2).
       ``(b) Plans.--
       ``(1) Development.--The Secretary, acting through the 
     Service, shall encourage Indian Tribes and Tribal 
     Organizations to develop tribal plans, and urban Indian 
     organizations to develop local plans, and for all such groups 
     to participate in developing areawide plans for Indian 
     Behavioral Health Services. The plans shall include, to the 
     extent feasible, the following components:
       ``(A) An assessment of the scope of alcohol or other 
     substance abuse, mental illness, and dysfunctional and self-
     destructive behavior, including suicide, child abuse, and 
     family violence, among Indians, including--
       ``(i) the number of Indians served who are directly or 
     indirectly affected by such illness or behavior; or
       ``(ii) an estimate of the financial and human cost 
     attributable to such illness or behavior.
       ``(B) An assessment of the existing and additional 
     resources necessary for the prevention and treatment of such 
     illness and behavior, including an assessment of the progress 
     toward achieving the availability of the full continuum of 
     care described in subsection (c).
       ``(C) An estimate of the additional funding needed by the 
     Service, Indian Tribes, Tribal Organizations, and urban 
     Indian organizations to meet their responsibilities under the 
     plans.
       ``(2) National clearinghouse.--The Secretary, acting 
     through the Service, shall coordinate with existing national 
     clearinghouses and information centers to include at the 
     clearinghouses and centers plans and reports on the outcomes 
     of such plans developed by Indian Tribes, Tribal 
     Organizations, urban Indian organizations, and Service Areas 
     relating to behavioral health. The Secretary shall ensure 
     access to these plans and outcomes by any Indian Tribe, 
     Tribal Organization, urban Indian organization, or the 
     Service.
       ``(3) Technical assistance.--The Secretary shall provide 
     technical assistance to Indian Tribes, Tribal Organizations, 
     and urban Indian organizations in preparation of plans under 
     this section and in developing standards of care that may be 
     used and adopted locally.
       ``(c) Programs.--The Secretary, acting through the Service, 
     shall provide, to the extent feasible and if funding is 
     available, programs including the following:
       ``(1) Comprehensive care.--A comprehensive continuum of 
     behavioral health care which provides--
       ``(A) community-based prevention, intervention, outpatient, 
     and behavioral health aftercare;
       ``(B) detoxification (social and medical);
       ``(C) acute hospitalization;
       ``(D) intensive outpatient/day treatment;
       ``(E) residential treatment;
       ``(F) transitional living for those needing a temporary, 
     stable living environment that is supportive of treatment and 
     recovery goals;
       ``(G) emergency shelter;
       ``(H) intensive case management; and
       ``(I) diagnostic services.
       ``(2) Child care.--Behavioral health services for Indians 
     from birth through age 17, including--
       ``(A) preschool and school age fetal alcohol disorder 
     services, including assessment and behavioral intervention;
       ``(B) mental health and substance abuse services 
     (emotional, organic, alcohol, drug, inhalant, and tobacco);
       ``(C) identification and treatment of co-occurring 
     disorders and comorbidity;
       ``(D) prevention of alcohol, drug, inhalant, and tobacco 
     use;
       ``(E) early intervention, treatment, and aftercare;
       ``(F) promotion of healthy approaches to risk and safety 
     issues; and
       ``(G) identification and treatment of neglect and physical, 
     mental, and sexual abuse.
       ``(3) Adult care.--Behavioral health services for Indians 
     from age 18 through 55, including--
       ``(A) early intervention, treatment, and aftercare;
       ``(B) mental health and substance abuse services 
     (emotional, alcohol, drug, inhalant, and tobacco), including 
     sex specific services;
       ``(C) identification and treatment of co-occurring 
     disorders (dual diagnosis) and comorbidity;
       ``(D) promotion of healthy approaches for risk-related 
     behavior;
       ``(E) treatment services for women at risk of giving birth 
     to a child with a fetal alcohol disorder; and
       ``(F) sex specific treatment for sexual assault and 
     domestic violence.
       ``(4) Family care.--Behavioral health services for 
     families, including--
       ``(A) early intervention, treatment, and aftercare for 
     affected families;
       ``(B) treatment for sexual assault and domestic violence; 
     and
       ``(C) promotion of healthy approaches relating to 
     parenting, domestic violence, and other abuse issues.
       ``(5) Elder care.--Behavioral health services for Indians 
     56 years of age and older, including--
       ``(A) early intervention, treatment, and aftercare;
       ``(B) mental health and substance abuse services 
     (emotional, alcohol, drug, inhalant, and tobacco), including 
     sex specific services;
       ``(C) identification and treatment of co-occurring 
     disorders (dual diagnosis) and comorbidity;
       ``(D) promotion of healthy approaches to managing 
     conditions related to aging;
       ``(E) sex specific treatment for sexual assault, domestic 
     violence, neglect, physical and mental abuse and 
     exploitation; and
       ``(F) identification and treatment of dementias regardless 
     of cause.
       ``(d) Community Behavioral Health Plan.--
       ``(1) Establishment.--The governing body of any Indian 
     Tribe, Tribal Organization, or urban Indian organization may 
     adopt a resolution for the establishment of a community 
     behavioral health plan providing for the identification and 
     coordination of available resources and programs to identify, 
     prevent, or treat substance abuse, mental illness, or 
     dysfunctional and self-destructive behavior, including child 
     abuse and family violence, among its members or its service 
     population. This plan should include behavioral health 
     services, social services, intensive outpatient services, and 
     continuing aftercare.
       ``(2) Technical assistance.--At the request of an Indian 
     Tribe, Tribal Organization, or urban Indian organization, the 
     Bureau of Indian Affairs and the Service shall cooperate with 
     and provide technical assistance to the Indian Tribe, Tribal 
     Organization, or urban Indian organization in the development 
     and implementation of such plan.
       ``(3) Funding.--The Secretary, acting through the Service, 
     may make funding available to Indian Tribes and Tribal 
     Organizations which adopt a resolution pursuant to paragraph 
     (1) to obtain technical assistance for the development of a 
     community behavioral health plan and to provide 
     administrative support in the implementation of such plan.
       ``(e) Coordination for Availability of Services.--The 
     Secretary, acting through the Service, shall coordinate 
     behavioral health planning, to the extent feasible, with 
     other Federal agencies and with State agencies, to encourage 
     comprehensive behavioral health services for Indians 
     regardless of their place of residence.
       ``(f) Mental Health Care Need Assessment.--Not later than 1 
     year after the date of enactment of the Indian Health Care 
     Improvement Act Amendments of 2009, the Secretary, acting 
     through the Service, shall make an assessment of the need for 
     inpatient mental health care among Indians and the 
     availability and cost of inpatient mental health facilities 
     which can meet such need. In making such assessment, the 
     Secretary shall consider the possible conversion of existing, 
     underused Service hospital beds into psychiatric units to 
     meet such need.

     ``SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE 
                   INTERIOR.

       ``(a) Contents.--Not later than 12 months after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary, acting through the 
     Service, and the Secretary of the Interior shall develop and 
     enter into a memoranda of agreement, or review and update any 
     existing memoranda of agreement, as required by section 4205 
     of the Indian Alcohol and Substance Abuse Prevention and 
     Treatment Act of 1986 (25 U.S.C. 2411) under which the 
     Secretaries address the following:
       ``(1) The scope and nature of mental illness and 
     dysfunctional and self-destructive behavior, including child 
     abuse and family violence, among Indians.
       ``(2) The existing Federal, tribal, State, local, and 
     private services, resources, and programs available to 
     provide behavioral health services for Indians.
       ``(3) The unmet need for additional services, resources, 
     and programs necessary to meet the needs identified pursuant 
     to paragraph (1).
       ``(4)(A) The right of Indians, as citizens of the United 
     States and of the States in which they reside, to have access 
     to behavioral health services to which all citizens have 
     access.
       ``(B) The right of Indians to participate in, and receive 
     the benefit of, such services.
       ``(C) The actions necessary to protect the exercise of such 
     right.
       ``(5) The responsibilities of the Bureau of Indian Affairs 
     and the Service, including mental illness identification, 
     prevention, education, referral, and treatment services 
     (including services through multidisciplinary resource 
     teams), at the central, area,

[[Page 27422]]

      and agency and Service Unit, Service Area, and headquarters 
     levels to address the problems identified in paragraph (1).
       ``(6) A strategy for the comprehensive coordination of the 
     behavioral health services provided by the Bureau of Indian 
     Affairs and the Service to meet the problems identified 
     pursuant to paragraph (1), including--
       ``(A) the coordination of alcohol and substance abuse 
     programs of the Service, the Bureau of Indian Affairs, and 
     Indian Tribes and Tribal Organizations (developed under the 
     Indian Alcohol and Substance Abuse Prevention and Treatment 
     Act of 1986 (25 U.S.C. 2401 et seq.)) with behavioral health 
     initiatives pursuant to this Act, particularly with respect 
     to the referral and treatment of dually diagnosed individuals 
     requiring behavioral health and substance abuse treatment; 
     and
       ``(B) ensuring that the Bureau of Indian Affairs and 
     Service programs and services (including multidisciplinary 
     resource teams) addressing child abuse and family violence 
     are coordinated with such non-Federal programs and services.
       ``(7) Directing appropriate officials of the Bureau of 
     Indian Affairs and the Service, particularly at the agency 
     and Service Unit levels, to cooperate fully with tribal 
     requests made pursuant to community behavioral health plans 
     adopted under section 701(c) and section 4206 of the Indian 
     Alcohol and Substance Abuse Prevention and Treatment Act of 
     1986 (25 U.S.C. 2412).
       ``(8) Providing for an annual review of such agreement by 
     the Secretaries which shall be provided to Congress and 
     Indian Tribes and Tribal Organizations.
       ``(b) Specific Provisions Required.--The memoranda of 
     agreement updated or entered into pursuant to subsection (a) 
     shall include specific provisions pursuant to which the 
     Service shall assume responsibility for--
       ``(1) the determination of the scope of the problem of 
     alcohol and substance abuse among Indians, including the 
     number of Indians within the jurisdiction of the Service who 
     are directly or indirectly affected by alcohol and substance 
     abuse and the financial and human cost;
       ``(2) an assessment of the existing and needed resources 
     necessary for the prevention of alcohol and substance abuse 
     and the treatment of Indians affected by alcohol and 
     substance abuse; and
       ``(3) an estimate of the funding necessary to adequately 
     support a program of prevention of alcohol and substance 
     abuse and treatment of Indians affected by alcohol and 
     substance abuse.
       ``(c) Publication.--Each memorandum of agreement entered 
     into or renewed (and amendments or modifications thereto) 
     under subsection (a) shall be published in the Federal 
     Register. At the same time as publication in the Federal 
     Register, the Secretary shall provide a copy of such 
     memoranda, amendment, or modification to each Indian Tribe, 
     Tribal Organization, and urban Indian organization.

     ``SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND 
                   TREATMENT PROGRAM.

       ``(a) Establishment.--
       ``(1) In general.--The Secretary, acting through the 
     Service, shall provide a program of comprehensive behavioral 
     health, prevention, treatment, and aftercare, including 
     Systems of Care, which shall include--
       ``(A) prevention, through educational intervention, in 
     Indian communities;
       ``(B) acute detoxification, psychiatric hospitalization, 
     residential, and intensive outpatient treatment;
       ``(C) community-based rehabilitation and aftercare;
       ``(D) community education and involvement, including 
     extensive training of health care, educational, and 
     community-based personnel;
       ``(E) specialized residential treatment programs for high-
     risk populations, including pregnant and postpartum women and 
     their children; and
       ``(F) diagnostic services.
       ``(2) Target populations.--The target population of such 
     programs shall be members of Indian Tribes. Efforts to train 
     and educate key members of the Indian community shall also 
     target employees of health, education, judicial, law 
     enforcement, legal, and social service programs.
       ``(b) Contract Health Services.--
       ``(1) In general.--The Secretary, acting through the 
     Service, may enter into contracts with public or private 
     providers of behavioral health treatment services for the 
     purpose of carrying out the program required under subsection 
     (a).
       ``(2) Provision of assistance.--In carrying out this 
     subsection, the Secretary shall provide assistance to Indian 
     Tribes and Tribal Organizations to develop criteria for the 
     certification of behavioral health service providers and 
     accreditation of service facilities which meet minimum 
     standards for such services and facilities.

     ``SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

       ``(a) In General.--Under the authority of the Act of 
     November 2, 1921 (25 U.S.C. 13) (commonly known as the 
     `Snyder Act'), the Secretary shall establish and maintain a 
     mental health technician program within the Service which--
       ``(1) provides for the training of Indians as mental health 
     technicians; and
       ``(2) employs such technicians in the provision of 
     community-based mental health care that includes 
     identification, prevention, education, referral, and 
     treatment services.
       ``(b) Paraprofessional Training.--In carrying out 
     subsection (a), the Secretary, acting through the Service, 
     shall provide high-standard paraprofessional training in 
     mental health care necessary to provide quality care to the 
     Indian communities to be served. Such training shall be based 
     upon a curriculum developed or approved by the Secretary 
     which combines education in the theory of mental health care 
     with supervised practical experience in the provision of such 
     care.
       ``(c) Supervision and Evaluation of Technicians.--The 
     Secretary, acting through the Service, shall supervise and 
     evaluate the mental health technicians in the training 
     program.
       ``(d) Traditional Health Care Practices.--The Secretary, 
     acting through the Service, shall ensure that the program 
     established pursuant to this subsection involves the use and 
     promotion of the traditional health care practices of the 
     Indian Tribes to be served.

     ``SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE 
                   WORKERS.

       ``(a) In General.--Subject to the provisions of section 
     221, and except as provided in subsection (b), any individual 
     employed as a psychologist, social worker, or marriage and 
     family therapist for the purpose of providing mental health 
     care services to Indians in a clinical setting under this Act 
     is required to be licensed as a psychologist, social worker, 
     or marriage and family therapist, respectively.
       ``(b) Trainees.--An individual may be employed as a trainee 
     in psychology, social work, or marriage and family therapy to 
     provide mental health care services described in subsection 
     (a) if such individual--
       ``(1) works under the direct supervision of a licensed 
     psychologist, social worker, or marriage and family 
     therapist, respectively;
       ``(2) is enrolled in or has completed at least 2 years of 
     course work at a post-secondary, accredited education program 
     for psychology, social work, marriage and family therapy, or 
     counseling; and
       ``(3) meets such other training, supervision, and quality 
     review requirements as the Secretary may establish.

     ``SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

       ``(a) Grants.--The Secretary, consistent with section 701, 
     may make grants to Indian Tribes, Tribal Organizations, and 
     urban Indian organizations to develop and implement a 
     comprehensive behavioral health program of prevention, 
     intervention, treatment, and relapse prevention services that 
     specifically addresses the cultural, historical, social, and 
     child care needs of Indian women, regardless of age.
       ``(b) Use of Grant Funds.--A grant made pursuant to this 
     section may be used to--
       ``(1) develop and provide community training, education, 
     and prevention programs for Indian women relating to 
     behavioral health issues, including fetal alcohol disorders;
       ``(2) identify and provide psychological services, 
     counseling, advocacy, support, and relapse prevention to 
     Indian women and their families; and
       ``(3) develop prevention and intervention models for Indian 
     women which incorporate traditional health care practices, 
     cultural values, and community and family involvement.
       ``(c) Criteria.--The Secretary, in consultation with Indian 
     Tribes and Tribal Organizations, shall establish criteria for 
     the review and approval of applications and proposals for 
     funding under this section.
       ``(d) Allocation of Funds for Urban Indian Organizations.--
     Twenty percent of the funds appropriated pursuant to this 
     section shall be used to make grants to urban Indian 
     organizations.

     ``SEC. 707. INDIAN YOUTH PROGRAM.

       ``(a) Detoxification and Rehabilitation.--The Secretary, 
     acting through the Service, consistent with section 701, 
     shall develop and implement a program for acute 
     detoxification and treatment for Indian youths, including 
     behavioral health services. The program shall include 
     regional treatment centers designed to include detoxification 
     and rehabilitation for both sexes on a referral basis and 
     programs developed and implemented by Indian Tribes or Tribal 
     Organizations at the local level under the Indian Self-
     Determination and Education Assistance Act (25 U.S.C. 450 et 
     seq.). Regional centers shall be integrated with the intake 
     and rehabilitation programs based in the referring Indian 
     community.
       ``(b) Alcohol and Substance Abuse Treatment Centers or 
     Facilities.--
       ``(1) Establishment.--
       ``(A) In general.--The Secretary, acting through the 
     Service, shall construct, renovate, or, as necessary, 
     purchase, and appropriately staff and operate, at least 1 
     youth regional treatment center or treatment network in each 
     area under the jurisdiction of an Area Office.
       ``(B) Area office in california.--For the purposes of this 
     subsection, the Area Office in California shall be considered 
     to be 2 Area Offices, 1 office whose jurisdiction shall be 
     considered to encompass the northern area

[[Page 27423]]

     of the State of California, and 1 office whose jurisdiction 
     shall be considered to encompass the remainder of the State 
     of California for the purpose of implementing California 
     treatment networks.
       ``(2) Funding.--For the purpose of staffing and operating 
     such centers or facilities, funding shall be pursuant to the 
     Act of November 2, 1921 (25 U.S.C. 13).
       ``(3) Location.--A youth treatment center constructed or 
     purchased under this subsection shall be constructed or 
     purchased at a location within the area described in 
     paragraph (1) agreed upon (by appropriate tribal resolution) 
     by a majority of the Indian Tribes to be served by such 
     center.
       ``(4) Specific provision of funds.--
       ``(A) In general.--Notwithstanding any other provision of 
     this title, the Secretary may, from amounts authorized to be 
     appropriated for the purposes of carrying out this section, 
     make funds available to--
       ``(i) the Tanana Chiefs Conference, Incorporated, for the 
     purpose of leasing, constructing, renovating, operating, and 
     maintaining a residential youth treatment facility in 
     Fairbanks, Alaska; and
       ``(ii) the Southeast Alaska Regional Health Corporation to 
     staff and operate a residential youth treatment facility 
     without regard to the proviso set forth in section 4(l) of 
     the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450b(l)).
       ``(B) Provision of services to eligible youths.--Until 
     additional residential youth treatment facilities are 
     established in Alaska pursuant to this section, the 
     facilities specified in subparagraph (A) shall make every 
     effort to provide services to all eligible Indian youths 
     residing in Alaska.
       ``(c) Intermediate Adolescent Behavioral Health Services.--
       ``(1) In general.--The Secretary, acting through the 
     Service, may provide intermediate behavioral health services, 
     which may incorporate Systems of Care, to Indian children and 
     adolescents, including--
       ``(A) pretreatment assistance;
       ``(B) inpatient, outpatient, and aftercare services;
       ``(C) emergency care;
       ``(D) suicide prevention and crisis intervention; and
       ``(E) prevention and treatment of mental illness and 
     dysfunctional and self-destructive behavior, including child 
     abuse and family violence.
       ``(2) Use of funds.--Funds provided under this subsection 
     may be used--
       ``(A) to construct or renovate an existing health facility 
     to provide intermediate behavioral health services;
       ``(B) to hire behavioral health professionals;
       ``(C) to staff, operate, and maintain an intermediate 
     mental health facility, group home, sober housing, 
     transitional housing or similar facilities, or youth shelter 
     where intermediate behavioral health services are being 
     provided;
       ``(D) to make renovations and hire appropriate staff to 
     convert existing hospital beds into adolescent psychiatric 
     units; and
       ``(E) for intensive home- and community-based services.
       ``(3) Criteria.--The Secretary, acting through the Service, 
     shall, in consultation with Indian Tribes and Tribal 
     Organizations, establish criteria for the review and approval 
     of applications or proposals for funding made available 
     pursuant to this subsection.
       ``(d) Federally Owned Structures.--
       ``(1) In general.--The Secretary, in consultation with 
     Indian Tribes and Tribal Organizations, shall--
       ``(A) identify and use, where appropriate, federally owned 
     structures suitable for local residential or regional 
     behavioral health treatment for Indian youths; and
       ``(B) establish guidelines for determining the suitability 
     of any such federally owned structure to be used for local 
     residential or regional behavioral health treatment for 
     Indian youths.
       ``(2) Terms and conditions for use of structure.--Any 
     structure described in paragraph (1) may be used under such 
     terms and conditions as may be agreed upon by the Secretary 
     and the agency having responsibility for the structure and 
     any Indian Tribe or Tribal Organization operating the 
     program.
       ``(e) Rehabilitation and Aftercare Services.--
       ``(1) In general.--The Secretary, Indian Tribes, or Tribal 
     Organizations, in cooperation with the Secretary of the 
     Interior, shall develop and implement within each Service 
     Unit, community-based rehabilitation and follow-up services 
     for Indian youths who are having significant behavioral 
     health problems, and require long-term treatment, community 
     reintegration, and monitoring to support the Indian youths 
     after their return to their home community.
       ``(2) Administration.--Services under paragraph (1) shall 
     be provided by trained staff within the community who can 
     assist the Indian youths in their continuing development of 
     self-image, positive problem-solving skills, and nonalcohol 
     or substance abusing behaviors. Such staff may include 
     alcohol and substance abuse counselors, mental health 
     professionals, and other health professionals and 
     paraprofessionals, including community health 
     representatives.
       ``(f) Inclusion of Family in Youth Treatment Program.--In 
     providing the treatment and other services to Indian youths 
     authorized by this section, the Secretary, acting through the 
     Service, shall provide for the inclusion of family members of 
     such youths in the treatment programs or other services as 
     may be appropriate. Not less than 10 percent of the funds 
     appropriated for the purposes of carrying out subsection (e) 
     shall be used for outpatient care of adult family members 
     related to the treatment of an Indian youth under that 
     subsection.
       ``(g) Multidrug Abuse Program.--The Secretary, acting 
     through the Service, shall provide, consistent with section 
     701, programs and services to prevent and treat the abuse of 
     multiple forms of substances, including alcohol, drugs, 
     inhalants, and tobacco, among Indian youths residing in 
     Indian communities, on or near reservations, and in urban 
     areas and provide appropriate mental health services to 
     address the incidence of mental illness among such youths.
       ``(h) Indian Youth Mental Health.--The Secretary, acting 
     through the Service, shall collect data for the report under 
     section 801 with respect to--
       ``(1) the number of Indian youth who are being provided 
     mental health services through the Service and Tribal Health 
     Programs;
       ``(2) a description of, and costs associated with, the 
     mental health services provided for Indian youth through the 
     Service and Tribal Health Programs;
       ``(3) the number of youth referred to the Service or Tribal 
     Health Programs for mental health services;
       ``(4) the number of Indian youth provided residential 
     treatment for mental health and behavioral problems through 
     the Service and Tribal Health Programs, reported separately 
     for on- and off-reservation facilities; and
       ``(5) the costs of the services described in paragraph (4).

     ``SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION 
                   PROJECT.

       ``(a) Purpose.--The purpose of this section is to authorize 
     the Secretary to carry out a demonstration project to test 
     the use of telemental health services in suicide prevention, 
     intervention and treatment of Indian youth, including 
     through--
       ``(1) the use of psychotherapy, psychiatric assessments, 
     diagnostic interviews, therapies for mental health conditions 
     predisposing to suicide, and alcohol and substance abuse 
     treatment;
       ``(2) the provision of clinical expertise to, consultation 
     services with, and medical advice and training for frontline 
     health care providers working with Indian youth;
       ``(3) training and related support for community leaders, 
     family members and health and education workers who work with 
     Indian youth;
       ``(4) the development of culturally relevant educational 
     materials on suicide; and
       ``(5) data collection and reporting.
       ``(b) Definitions.--For the purpose of this section, the 
     following definitions shall apply:
       ``(1) Demonstration project.--The term `demonstration 
     project' means the Indian youth telemental health 
     demonstration project authorized under subsection (c).
       ``(2) Telemental health.--The term `telemental health' 
     means the use of electronic information and 
     telecommunications technologies to support long distance 
     mental health care, patient and professional-related 
     education, public health, and health administration.
       ``(c) Authorization.--
       ``(1) In general.--The Secretary is authorized to award 
     grants under the demonstration project for the provision of 
     telemental health services to Indian youth who--
       ``(A) have expressed suicidal ideas;
       ``(B) have attempted suicide; or
       ``(C) have mental health conditions that increase or could 
     increase the risk of suicide.
       ``(2) Eligibility for grants.--Such grants shall be awarded 
     to Indian Tribes and Tribal Organizations that operate 1 or 
     more facilities--
       ``(A) located in Alaska and part of the Alaska Federal 
     Health Care Access Network;
       ``(B) reporting active clinical telehealth capabilities; or
       ``(C) offering school-based telemental health services 
     relating to psychiatry to Indian youth.
       ``(3) Grant period.--The Secretary shall award grants under 
     this section for a period of up to 4 years.
       ``(4) Awarding of grants.--Not more than 5 grants shall be 
     provided under paragraph (1), with priority consideration 
     given to Indian Tribes and Tribal Organizations that--
       ``(A) serve a particular community or geographic area where 
     there is a demonstrated need to address Indian youth suicide;
       ``(B) enter in to collaborative partnerships with Indian 
     Health Service or Tribal Health Programs or facilities to 
     provide services under this demonstration project;
       ``(C) serve an isolated community or geographic area which 
     has limited or no access to behavioral health services; or
       ``(D) operate a detention facility at which Indian youth 
     are detained.
       ``(d) Use of Funds.--
       ``(1) In general.--An Indian Tribe or Tribal Organization 
     shall use a grant received under subsection (c) for the 
     following purposes:
       ``(A) To provide telemental health services to Indian 
     youth, including the provision of--

[[Page 27424]]

       ``(i) psychotherapy;
       ``(ii) psychiatric assessments and diagnostic interviews, 
     therapies for mental health conditions predisposing to 
     suicide, and treatment; and
       ``(iii) alcohol and substance abuse treatment.
       ``(B) To provide clinician-interactive medical advice, 
     guidance and training, assistance in diagnosis and 
     interpretation, crisis counseling and intervention, and 
     related assistance to Service, tribal, or urban clinicians 
     and health services providers working with youth being served 
     under this demonstration project.
       ``(C) To assist, educate and train community leaders, 
     health education professionals and paraprofessionals, tribal 
     outreach workers, and family members who work with the youth 
     receiving telemental health services under this demonstration 
     project, including with identification of suicidal 
     tendencies, crisis intervention and suicide prevention, 
     emergency skill development, and building and expanding 
     networks among these individuals and with State and local 
     health services providers.
       ``(D) To develop and distribute culturally appropriate 
     community educational materials on--
       ``(i) suicide prevention;
       ``(ii) suicide education;
       ``(iii) suicide screening;
       ``(iv) suicide intervention; and
       ``(v) ways to mobilize communities with respect to the 
     identification of risk factors for suicide.
       ``(E) For data collection and reporting related to Indian 
     youth suicide prevention efforts.
       ``(2) Traditional health care practices.--In carrying out 
     the purposes described in paragraph (1), an Indian Tribe or 
     Tribal Organization may use and promote the traditional 
     health care practices of the Indian Tribes of the youth to be 
     served.
       ``(e) Applications.--To be eligible to receive a grant 
     under subsection (c), an Indian Tribe or Tribal Organization 
     shall prepare and submit to the Secretary an application, at 
     such time, in such manner, and containing such information as 
     the Secretary may require, including--
       ``(1) a description of the project that the Indian Tribe or 
     Tribal Organization will carry out using the funds provided 
     under the grant;
       ``(2) a description of the manner in which the project 
     funded under the grant would--
       ``(A) meet the telemental health care needs of the Indian 
     youth population to be served by the project; or
       ``(B) improve the access of the Indian youth population to 
     be served to suicide prevention and treatment services;
       ``(3) evidence of support for the project from the local 
     community to be served by the project;
       ``(4) a description of how the families and leadership of 
     the communities or populations to be served by the project 
     would be involved in the development and ongoing operations 
     of the project;
       ``(5) a plan to involve the tribal community of the youth 
     who are provided services by the project in planning and 
     evaluating the mental health care and suicide prevention 
     efforts provided, in order to ensure the integration of 
     community, clinical, environmental, and cultural components 
     of the treatment; and
       ``(6) a plan for sustaining the project after Federal 
     assistance for the demonstration project has terminated.
       ``(f) Collaboration; Reporting to National Clearinghouse.--
       ``(1) Collaboration.--The Secretary, acting through the 
     Service, shall encourage Indian Tribes and Tribal 
     Organizations receiving grants under this section to 
     collaborate to enable comparisons about best practices across 
     projects.
       ``(2) Reporting to national clearinghouse.--The Secretary, 
     acting through the Service, shall also encourage Indian 
     Tribes and Tribal Organizations receiving grants under this 
     section to submit relevant, declassified project information 
     to the national clearinghouse authorized under section 
     701(b)(2) in order to better facilitate program performance 
     and improve suicide prevention, intervention, and treatment 
     services.
       ``(g) Annual Report.--Each grant recipient shall submit to 
     the Secretary an annual report that--
       ``(1) describes the number of telemental health services 
     provided; and
       ``(2) includes any other information that the Secretary may 
     require.
       ``(h) Report to Congress.--Not later than 270 days after 
     the termination of the demonstration project, the Secretary 
     shall submit to the Committee on Indian Affairs of the Senate 
     and the Committee on Natural Resources and Committee on 
     Energy and Commerce of the House of Representatives a final 
     report, based on the annual reports provided by grant 
     recipients under subsection (h), that--
       ``(1) describes the results of the projects funded by 
     grants awarded under this section, including any data 
     available which indicates the number of attempted suicides;
       ``(2) evaluates the impact of the telemental health 
     services funded by the grants in reducing the number of 
     completed suicides among Indian youth;
       ``(3) evaluates whether the demonstration project should 
     be--
       ``(A) expanded to provide more than 5 grants; and
       ``(B) designated a permanent program; and
       ``(4) evaluates the benefits of expanding the demonstration 
     project to include urban Indian organizations.
       ``(i) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     ``SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH 
                   FACILITIES DESIGN, CONSTRUCTION, AND STAFFING.

       ``Not later than 1 year after the date of enactment of the 
     Indian Health Care Improvement Act Amendments of 2009, the 
     Secretary, acting through the Service, may provide, in each 
     area of the Service, not less than 1 inpatient mental health 
     care facility, or the equivalent, for Indians with behavioral 
     health problems. For the purposes of this subsection, 
     California shall be considered to be 2 Area Offices, 1 office 
     whose location shall be considered to encompass the northern 
     area of the State of California and 1 office whose 
     jurisdiction shall be considered to encompass the remainder 
     of the State of California. The Secretary shall consider the 
     possible conversion of existing, underused Service hospital 
     beds into psychiatric units to meet such need.

     ``SEC. 710. TRAINING AND COMMUNITY EDUCATION.

       ``(a) Program.--The Secretary, in cooperation with the 
     Secretary of the Interior, shall develop and implement or 
     assist Indian Tribes and Tribal Organizations to develop and 
     implement, within each Service Unit or tribal program, a 
     program of community education and involvement which shall be 
     designed to provide concise and timely information to the 
     community leadership of each tribal community. Such program 
     shall include education about behavioral health issues to 
     political leaders, Tribal judges, law enforcement personnel, 
     members of tribal health and education boards, health care 
     providers including traditional practitioners, and other 
     critical members of each tribal community. Such program may 
     also include community-based training to develop local 
     capacity and tribal community provider training for 
     prevention, intervention, treatment, and aftercare.
       ``(b) Instruction.--The Secretary, acting through the 
     Service, shall provide instruction in the area of behavioral 
     health issues, including instruction in crisis intervention 
     and family relations in the context of alcohol and substance 
     abuse, child sexual abuse, youth alcohol and substance abuse, 
     and the causes and effects of fetal alcohol disorders to 
     appropriate employees of the Bureau of Indian Affairs and the 
     Service, and to personnel in schools or programs operated 
     under any contract with the Bureau of Indian Affairs or the 
     Service, including supervisors of emergency shelters and 
     halfway houses described in section 4213 of the Indian 
     Alcohol and Substance Abuse Prevention and Treatment Act of 
     1986 (25 U.S.C. 2433).
       ``(c) Training Models.--In carrying out the education and 
     training programs required by this section, the Secretary, in 
     consultation with Indian Tribes, Tribal Organizations, Indian 
     behavioral health experts, and Indian alcohol and substance 
     abuse prevention experts, shall develop and provide 
     community-based training models. Such models shall address--
       ``(1) the elevated risk of alcohol and behavioral health 
     problems faced by children of alcoholics;
       ``(2) the cultural, spiritual, and multigenerational 
     aspects of behavioral health problem prevention and recovery; 
     and
       ``(3) community-based and multidisciplinary strategies, 
     including Systems of Care, for preventing and treating 
     behavioral health problems.

     ``SEC. 711. BEHAVIORAL HEALTH PROGRAM.

       ``(a) Innovative Programs.--The Secretary, acting through 
     the Service, consistent with section 701, may plan, develop, 
     implement, and carry out programs to deliver innovative 
     community-based behavioral health services to Indians.
       ``(b) Awards; Criteria.--The Secretary may award a grant 
     for a project under subsection (a) to an Indian Tribe or 
     Tribal Organization and may consider the following criteria:
       ``(1) The project will address significant unmet behavioral 
     health needs among Indians.
       ``(2) The project will serve a significant number of 
     Indians.
       ``(3) The project has the potential to deliver services in 
     an efficient and effective manner.
       ``(4) The Indian Tribe or Tribal Organization has the 
     administrative and financial capability to administer the 
     project.
       ``(5) The project may deliver services in a manner 
     consistent with traditional health care practices.
       ``(6) The project is coordinated with, and avoids 
     duplication of, existing services.
       ``(c) Equitable Treatment.--For purposes of this 
     subsection, the Secretary shall, in evaluating project 
     applications or proposals,

[[Page 27425]]

     use the same criteria that the Secretary uses in evaluating 
     any other application or proposal for such funding.

     ``SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.

       ``(a) Programs.--
       ``(1) Establishment.--The Secretary, consistent with 
     section 701 and acting through the Service, is authorized to 
     establish and operate fetal alcohol disorder programs as 
     provided in this section for the purposes of meeting the 
     health status objectives specified in section 3.
       ``(2) Use of funds.--
       ``(A) In general.--Funding provided pursuant to this 
     section shall be used for the following:
       ``(i) To develop and provide for Indians community and in-
     school training, education, and prevention programs relating 
     to fetal alcohol disorders.
       ``(ii) To identify and provide behavioral health treatment 
     to high-risk Indian women and high-risk women pregnant with 
     an Indian's child.
       ``(iii) To identify and provide appropriate psychological 
     services, educational and vocational support, counseling, 
     advocacy, and information to fetal alcohol disorder affected 
     Indians and their families or caretakers.
       ``(iv) To develop and implement counseling and support 
     programs in schools for fetal alcohol disorder affected 
     Indian children.
       ``(v) To develop prevention and intervention models which 
     incorporate practitioners of traditional health care 
     practices, cultural values, and community involvement.
       ``(vi) To develop, print, and disseminate education and 
     prevention materials on fetal alcohol disorder.
       ``(vii) To develop and implement, in consultation with 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations, culturally sensitive assessment and diagnostic 
     tools including dysmorphology clinics and multidisciplinary 
     fetal alcohol disorder clinics for use in Indian communities 
     and Urban Centers.
       ``(B) Additional uses.--In addition to any purpose under 
     subparagraph (A), funding provided pursuant to this section 
     may be used for 1 or more of the following:
       ``(i) Early childhood intervention projects from birth on 
     to mitigate the effects of fetal alcohol disorder among 
     Indians.
       ``(ii) Community-based support services for Indians and 
     women pregnant with Indian children.
       ``(iii) Community-based housing for adult Indians with 
     fetal alcohol disorder.
       ``(3) Criteria for applications.--The Secretary shall 
     establish criteria for the review and approval of 
     applications for funding under this section.
       ``(b) Services.--The Secretary, acting through the Service, 
     shall--
       ``(1) develop and provide services for the prevention, 
     intervention, treatment, and aftercare for those affected by 
     fetal alcohol disorder in Indian communities; and
       ``(2) provide supportive services, including services to 
     meet the special educational, vocational, school-to-work 
     transition, and independent living needs of adolescent and 
     adult Indians with fetal alcohol disorder.
       ``(c) Task Force.--The Secretary shall establish a task 
     force to be known as the Fetal Alcohol Disorder Task Force to 
     advise the Secretary in carrying out subsection (b). Such 
     task force shall be composed of representatives from the 
     following:
       ``(1) The National Institute on Drug Abuse.
       ``(2) The National Institute on Alcohol and Alcoholism.
       ``(3) The Office of Substance Abuse Prevention.
       ``(4) The National Institute of Mental Health.
       ``(5) The Service.
       ``(6) The Office of Minority Health of the Department of 
     Health and Human Services.
       ``(7) The Administration for Native Americans.
       ``(8) The National Institute of Child Health and Human 
     Development (NICHD).
       ``(9) The Centers for Disease Control and Prevention.
       ``(10) The Bureau of Indian Affairs.
       ``(11) Indian Tribes.
       ``(12) Tribal Organizations.
       ``(13) urban Indian organizations.
       ``(14) Indian fetal alcohol spectrum disorders experts.
       ``(d) Applied Research Projects.--The Secretary, acting 
     through the Substance Abuse and Mental Health Services 
     Administration, shall make grants to Indian Tribes, Tribal 
     Organizations, and urban Indian organizations for applied 
     research projects which propose to elevate the understanding 
     of methods to prevent, intervene, treat, or provide 
     rehabilitation and behavioral health aftercare for Indians 
     and urban Indians affected by fetal alcohol spectrum 
     disorders.
       ``(e) Funding for Urban Indian Organizations.--Ten percent 
     of the funds appropriated pursuant to this section shall be 
     used to make grants to urban Indian organizations funded 
     under title V.

     ``SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT 
                   PROGRAMS.

       ``(a) Establishment.--The Secretary, acting through the 
     Service, shall establish, consistent with section 701, in 
     every Service Area, programs involving treatment for--
       ``(1) victims of sexual abuse who are Indian children or 
     children in an Indian household; and
       ``(2) perpetrators of child sexual abuse who are Indian or 
     members of an Indian household.
       ``(b) Use of Funds.--Funding provided pursuant to this 
     section shall be used for the following:
       ``(1) To develop and provide community education and 
     prevention programs related to sexual abuse of Indian 
     children or children in an Indian household.
       ``(2) To identify and provide behavioral health treatment 
     to victims of sexual abuse who are Indian children or 
     children in an Indian household, and to their family members 
     who are affected by sexual abuse.
       ``(3) To develop prevention and intervention models which 
     incorporate traditional health care practices, cultural 
     values, and community involvement.
       ``(4) To develop and implement culturally sensitive 
     assessment and diagnostic tools for use in Indian communities 
     and Urban Centers.
       ``(5) To identify and provide behavioral health treatment 
     to Indian perpetrators and perpetrators who are members of an 
     Indian household--
       ``(A) making efforts to begin offender and behavioral 
     health treatment while the perpetrator is incarcerated or at 
     the earliest possible date if the perpetrator is not 
     incarcerated; and
       ``(B) providing treatment after the perpetrator is 
     released, until it is determined that the perpetrator is not 
     a threat to children.
       ``(c) Coordination.--The programs established under 
     subsection (a) shall be carried out in coordination with 
     programs and services authorized under the Indian Child 
     Protection and Family Violence Prevention Act (25 U.S.C. 3201 
     et seq.).

     ``SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION AND 
                   TREATMENT.

       ``(a) In General.--The Secretary, in accordance with 
     section 701, is authorized to establish in each Service Area 
     programs involving the prevention and treatment of--
       ``(1) Indian victims of domestic violence or sexual abuse; 
     and
       ``(2) perpetrators of domestic violence or sexual abuse who 
     are Indian or members of an Indian household.
       ``(b) Use of Funds.--Funds made available to carry out this 
     section shall be used--
       ``(1) to develop and implement prevention programs and 
     community education programs relating to domestic violence 
     and sexual abuse;
       ``(2) to provide behavioral health services, including 
     victim support services, and medical treatment (including 
     examinations performed by sexual assault nurse examiners) to 
     Indian victims of domestic violence or sexual abuse;
       ``(3) to purchase rape kits;
       ``(4) to develop prevention and intervention models, which 
     may incorporate traditional health care practices; and
       ``(5) to identify and provide behavioral health treatment 
     to perpetrators who are Indian or members of an Indian 
     household.
       ``(c) Training and Certification.--
       ``(1) In general.--Not later than 1 year after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary shall establish appropriate 
     protocols, policies, procedures, standards of practice, and, 
     if not available elsewhere, training curricula and training 
     and certification requirements for services for victims of 
     domestic violence and sexual abuse.
       ``(2) Report.--Not later than 18 months after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2008, the Secretary shall submit to the 
     Committee on Indian Affairs of the Senate and the Committee 
     on Natural Resources of the House of Representatives a report 
     that describes the means and extent to which the Secretary 
     has carried out paragraph (1).
       ``(d) Coordination.--
       ``(1) In general.--The Secretary, in coordination with the 
     Attorney General, Federal and tribal law enforcement 
     agencies, Indian Health Programs, and domestic violence or 
     sexual assault victim organizations, shall develop 
     appropriate victim services and victim advocate training 
     programs--
       ``(A) to improve domestic violence or sexual abuse 
     responses;
       ``(B) to improve forensic examinations and collection;
       ``(C) to identify problems or obstacles in the prosecution 
     of domestic violence or sexual abuse; and
       ``(D) to meet other needs or carry out other activities 
     required to prevent, treat, and improve prosecutions of 
     domestic violence and sexual abuse.
       ``(2) Report.--Not later than 2 years after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2008, the Secretary shall submit to the 
     Committee on Indian Affairs of the Senate and the Committee 
     on Natural Resources of the House of Representatives a report 
     that describes, with respect to the matters described in 
     paragraph (1), the improvements made and needed, problems or 
     obstacles identified, and costs necessary to address the 
     problems or obstacles, and any other recommendations that the 
     Secretary determines to be appropriate.

[[Page 27426]]



     ``SEC. 715. BEHAVIORAL HEALTH RESEARCH.

       ``The Secretary, in consultation with appropriate Federal 
     agencies, shall make grants to, or enter into contracts with, 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations or enter into contracts with, or make grants to 
     appropriate institutions for, the conduct of research on the 
     incidence and prevalence of behavioral health problems among 
     Indians served by the Service, Indian Tribes, or Tribal 
     Organizations and among Indians in urban areas. Research 
     priorities under this section shall include--
       ``(1) the multifactorial causes of Indian youth suicide, 
     including--
       ``(A) protective and risk factors and scientific data that 
     identifies those factors; and
       ``(B) the effects of loss of cultural identity and the 
     development of scientific data on those effects;
       ``(2) the interrelationship and interdependence of 
     behavioral health problems with alcoholism and other 
     substance abuse, suicide, homicides, other injuries, and the 
     incidence of family violence; and
       ``(3) the development of models of prevention techniques.
     The effect of the interrelationships and interdependencies 
     referred to in paragraph (2) on children, and the development 
     of prevention techniques under paragraph (3) applicable to 
     children, shall be emphasized.

     ``SEC. 716. DEFINITIONS.

       ``For the purpose of this title, the following definitions 
     shall apply:
       ``(1) Assessment.--The term `assessment' means the 
     systematic collection, analysis, and dissemination of 
     information on health status, health needs, and health 
     problems.
       ``(2) Alcohol-related neurodevelopmental disorders or 
     arnd.--The term `alcohol-related neurodevelopmental 
     disorders' or `ARND' means, with a history of maternal 
     alcohol consumption during pregnancy, central nervous system 
     involvement such as developmental delay, intellectual 
     deficit, or neurologic abnormalities. Behaviorally, there can 
     be problems with irritability, and failure to thrive as 
     infants. As children become older there will likely be 
     hyperactivity, attention deficit, language dysfunction, and 
     perceptual and judgment problems.
       ``(3) Behavioral health aftercare.--The term `behavioral 
     health aftercare' includes those activities and resources 
     used to support recovery following inpatient, residential, 
     intensive substance abuse, or mental health outpatient or 
     outpatient treatment. The purpose is to help prevent or deal 
     with relapse by ensuring that by the time a client or patient 
     is discharged from a level of care, such as outpatient 
     treatment, an aftercare plan has been developed with the 
     client. An aftercare plan may use such resources as a 
     community-based therapeutic group, transitional living 
     facilities, a 12-step sponsor, a local 12-step or other 
     related support group, and other community-based providers.
       ``(4) Dual diagnosis.--The term `dual diagnosis' means 
     coexisting substance abuse and mental illness conditions or 
     diagnosis. Such clients are sometimes referred to as mentally 
     ill chemical abusers (MICAs).
       ``(5) Fetal alcohol spectrum disorders.--
       ``(A) In general.--The term `fetal alcohol spectrum 
     disorders' includes a range of effects that can occur in an 
     individual whose mother drank alcohol during pregnancy, 
     including physical, mental, behavioral, and/or learning 
     disabilities with possible lifelong implications.
       ``(B) Inclusions.--The term `fetal alcohol spectrum 
     disorders' may include--
       ``(i) fetal alcohol syndrome (FAS);
       ``(ii) fetal alcohol effect (FAE);
       ``(iii) alcohol-related birth defects; and
       ``(iv) alcohol-related neurodevelopmental disorders (ARND).
       ``(6) Fetal alcohol syndrome or fas.--The term `fetal 
     alcohol syndrome' or `FAS' means any 1 of a spectrum of 
     effects that may occur when a woman drinks alcohol during 
     pregnancy, the diagnosis of which involves the confirmed 
     presence of the following 3 criteria:
       ``(A) Craniofacial abnormalities.
       ``(B) Growth deficits.
       ``(C) Central nervous system abnormalities.
       ``(7) Rehabilitation.--The term `rehabilitation' means 
     medical and health care services that--
       ``(A) are recommended by a physician or licensed 
     practitioner of the healing arts within the scope of their 
     practice under applicable law;
       ``(B) are furnished in a facility, home, or other setting 
     in accordance with applicable standards; and
       ``(C) have as their purpose any of the following:
       ``(i) The maximum attainment of physical, mental, and 
     developmental functioning.
       ``(ii) Averting deterioration in physical or mental 
     functional status.
       ``(iii) The maintenance of physical or mental health 
     functional status.
       ``(8) Substance abuse.--The term `substance abuse' includes 
     inhalant abuse.
       ``(9) Systems of care.--The term `Systems of Care' means a 
     system for delivering services to children and their families 
     that is child-centered, family-focused and family-driven, 
     community-based, and culturally competent and responsive to 
     the needs of the children and families being served. The 
     systems of care approach values prevention and early 
     identification, smooth transitions for children and families, 
     child and family participation and advocacy, comprehensive 
     array of services, individualized service planning, services 
     in the least restrictive environment, and integrated services 
     with coordinated planning across the child-serving systems.

     ``SEC. 717. AUTHORIZATION OF APPROPRIATIONS.

       ``There is authorized to be appropriated such sums as may 
     be necessary to carry out the provisions of this title.

                      ``TITLE VIII--MISCELLANEOUS

     ``SEC. 801. REPORTS.

       ``For each fiscal year following the date of enactment of 
     the Indian Health Care Improvement Act Amendments of 2009, 
     the Secretary shall transmit to Congress a report containing 
     the following:
       ``(1) A report on the progress made in meeting the 
     objectives of this Act, including a review of programs 
     established or assisted pursuant to this Act and assessments 
     and recommendations of additional programs or additional 
     assistance necessary to, at a minimum, provide health 
     services to Indians and ensure a health status for Indians, 
     which are at a parity with the health services available to 
     and the health status of the general population.
       ``(2) A report on whether, and to what extent, new national 
     health care programs, benefits, initiatives, or financing 
     systems have had an impact on the purposes of this Act and 
     any steps that the Secretary may have taken to consult with 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations to address such impact, including a report on 
     proposed changes in allocation of funding pursuant to section 
     807.
       ``(3) A report on the use of health services by Indians--
       ``(A) on a national and area or other relevant geographical 
     basis;
       ``(B) by gender and age;
       ``(C) by source of payment and type of service;
       ``(D) comparing such rates of use with rates of use among 
     comparable non-Indian populations; and
       ``(E) provided under contracts.
       ``(4) A report of contractors to the Secretary on Health 
     Care Educational Loan Repayments every 6 months required by 
     section 110.
       ``(5) A general audit report of the Secretary on the Health 
     Care Educational Loan Repayment Program as required by 
     section 110(m).
       ``(6) A report of the findings and conclusions of 
     demonstration programs on development of educational 
     curricula for substance abuse counseling as required in 
     section 125(f).
       ``(7) A separate statement which specifies the amount of 
     funds requested to carry out the provisions of section 201.
       ``(8) A report of the evaluations of health promotion and 
     disease prevention as required in section 203(c).
       ``(9) A biennial report to Congress on infectious diseases 
     as required by section 212.
       ``(10) A report on environmental and nuclear health hazards 
     as required by section 215.
       ``(11) An annual report on the status of all health care 
     facilities needs as required by section 301(c)(2)(B) and 
     301(d).
       ``(12) Reports on safe water and sanitary waste disposal 
     facilities as required by section 302(h).
       ``(13) An annual report on the expenditure of non-Service 
     funds for renovation as required by sections 304(b)(2).
       ``(14) A report identifying the backlog of maintenance and 
     repair required at Service and tribal facilities required by 
     section 313(a).
       ``(15) A report providing an accounting of reimbursement 
     funds made available to the Secretary under titles XVIII, 
     XIX, and XXI of the Social Security Act.
       ``(16) A report on any arrangements for the sharing of 
     medical facilities or services, as authorized by section 406.
       ``(17) A report on evaluation and renewal of urban Indian 
     programs under section 505.
       ``(18) A report on the evaluation of programs as required 
     by section 513(d).
       ``(19) A report on alcohol and substance abuse as required 
     by section 701(f).
       ``(20) A report on Indian youth mental health services as 
     required by section 707(h).
       ``(21) A report on the reallocation of base resources if 
     required by section 807.
       ``(22) A report on the movement of patients between Service 
     Units, including--
       ``(A) a list of those Service Units that have a net 
     increase and those that have a net decrease of patients due 
     to patients assigned to one Service Unit voluntarily choosing 
     to receive service at another Service Unit;
       ``(B) an analysis of the effect of patient movement on the 
     quality of services for those Service Units experiencing an 
     increase in the number of patients served; and
       ``(C) what funding changes are necessary to maintain a 
     consistent quality of service at Service Units that have an 
     increase in the number of patients served.
       ``(23) A report on the extent to which health care 
     facilities of the Service, Indian Tribes, Tribal 
     Organizations, and urban Indian organizations comply with 
     credentialing requirements of the Service or licensure 
     requirements of States.

[[Page 27427]]



     ``SEC. 802. REGULATIONS.

       ``(a) Deadlines.--
       ``(1) Procedures.--Not later than 90 days after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary shall initiate procedures 
     under subchapter III of chapter 5 of title 5, United States 
     Code, to negotiate and promulgate such regulations or 
     amendments thereto that are necessary to carry out this Act, 
     except sections 105, 115, 117, 202, and 409 through 414. The 
     Secretary may promulgate regulations to carry out such 
     sections using the procedures required by chapter 5 of title 
     5, United States Code (commonly known as the `Administrative 
     Procedure Act').
       ``(2) Proposed regulations.--Proposed regulations to 
     implement this Act shall be published in the Federal Register 
     by the Secretary no later than 2 years after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009 and shall have no less than a 120-day 
     comment period.
       ``(3) Final regulations.--The Secretary shall publish in 
     the Federal Register final regulations to implement this Act 
     by not later than 3 years after the date of enactment of the 
     Indian Health Care Improvement Act Amendments of 2009.
       ``(b) Committee.--A negotiated rulemaking committee 
     established pursuant to section 565 of title 5, United States 
     Code, to carry out this section shall have as its members 
     only representatives of the Federal Government and 
     representatives of Indian Tribes, and Tribal Organizations, a 
     majority of whom shall be nominated by and be representatives 
     of Indian Tribes and Tribal Organizations from each Service 
     Area.
       ``(c) Adaptation of Procedures.--The Secretary shall adapt 
     the negotiated rulemaking procedures to the unique context of 
     self-governance and the government-to-government relationship 
     between the United States and Indian Tribes.
       ``(d) Lack of Regulations.--The lack of promulgated 
     regulations shall not limit the effect of this Act.

     ``SEC. 803. PLAN OF IMPLEMENTATION.

       ``(a) In General.--Not later than 1 year after the date of 
     enactment of the Indian Health Care Improvement Act 
     Amendments of 2009, the Secretary, in consultation with 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations, shall submit to Congress a plan explaining the 
     manner and schedule, by title and section, by which the 
     Secretary will implement the provisions of this Act. This 
     consultation may be conducted jointly with the annual budget 
     consultation pursuant to the Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450 et seq.).
       ``(b) Lack of Plan.--The lack of (or failure to submit) 
     such a plan shall not limit the effect, or prevent the 
     implementation, of this Act.

     ``SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN 
                   HEALTH SERVICE.

       ``Any limitation on the use of funds contained in an Act 
     providing appropriations for the Department for a period with 
     respect to the performance of abortions shall apply for that 
     period with respect to the performance of abortions using 
     funds contained in an Act providing appropriations for the 
     Service.

     ``SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS.

       ``(a) In General.--The following California Indians shall 
     be eligible for health services provided by the Service:
       ``(1) Any member of a federally recognized Indian Tribe.
       ``(2) Any descendant of an Indian who was residing in 
     California on June 1, 1852, if such descendant--
       ``(A) is a member of the Indian community served by a local 
     program of the Service; and
       ``(B) is regarded as an Indian by the community in which 
     such descendant lives.
       ``(3) Any Indian who holds trust interests in public 
     domain, national forest, or reservation allotments in 
     California.
       ``(4) Any Indian in California who is listed on the plans 
     for distribution of the assets of rancherias and reservations 
     located within the State of California under the Act of 
     August 18, 1958 (72 Stat. 619), and any descendant of such an 
     Indian.
       ``(b) Clarification.--Nothing in this section may be 
     construed as expanding the eligibility of California Indians 
     for health services provided by the Service beyond the scope 
     of eligibility for such health services that applied on May 
     1, 1986.

     ``SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS.

       ``(a) Children.--Any individual who--
       ``(1) has not attained 19 years of age;
       ``(2) is the natural or adopted child, stepchild, foster 
     child, legal ward, or orphan of an eligible Indian; and
       ``(3) is not otherwise eligible for health services 
     provided by the Service,
     shall be eligible for all health services provided by the 
     Service on the same basis and subject to the same rules that 
     apply to eligible Indians until such individual attains 19 
     years of age. The existing and potential health needs of all 
     such individuals shall be taken into consideration by the 
     Service in determining the need for, or the allocation of, 
     the health resources of the Service. If such an individual 
     has been determined to be legally incompetent prior to 
     attaining 19 years of age, such individual shall remain 
     eligible for such services until 1 year after the date of a 
     determination of competency.
       ``(b) Spouses.--Any spouse of an eligible Indian who is not 
     an Indian, or who is of Indian descent but is not otherwise 
     eligible for the health services provided by the Service, 
     shall be eligible for such health services if all such 
     spouses or spouses who are married to members of each Indian 
     Tribe being served are made eligible, as a class, by an 
     appropriate resolution of the governing body of the Indian 
     Tribe or Tribal Organization providing such services. The 
     health needs of persons made eligible under this paragraph 
     shall not be taken into consideration by the Service in 
     determining the need for, or allocation of, its health 
     resources.
       ``(c) Provision of Services to Other Individuals.--
       ``(1) In general.--The Secretary is authorized to provide 
     health services under this subsection through health programs 
     operated directly by the Service to individuals who reside 
     within the Service area of the Service Unit and who are not 
     otherwise eligible for such health services if--
       ``(A) the Indian Tribes served by such Service Unit request 
     such provision of health services to such individuals; and
       ``(B) the Secretary and the served Indian Tribes have 
     jointly determined that--
       ``(i) the provision of such health services will not result 
     in a denial or diminution of health services to eligible 
     Indians; and
       ``(ii) there is no reasonable alternative health facilities 
     or services, within or without the Service Unit, available to 
     meet the health needs of such individuals.
       ``(2) ISDEAA programs.--In the case of health programs and 
     facilities operated under a contract or compact entered into 
     under the Indian Self-Determination and Education Assistance 
     Act (25 U.S.C. 450 et seq.), the governing body of the Indian 
     Tribe or Tribal Organization providing health services under 
     such contract or compact is authorized to determine whether 
     health services should be provided under such contract to 
     individuals who are not eligible for such health services 
     under any other subsection of this section or under any other 
     provision of law. In making such determinations, the 
     governing body of the Indian Tribe or Tribal Organization 
     shall take into account the considerations described in 
     paragraph (1)(B).
       ``(3) Payment for services.--
       ``(A) In general.--Persons receiving health services 
     provided by the Service under this subsection shall be liable 
     for payment of such health services under a schedule of 
     charges prescribed by the Secretary which, in the judgment of 
     the Secretary, results in reimbursement in an amount not less 
     than the actual cost of providing the health services. 
     Notwithstanding section 404 of this Act or any other 
     provision of law, amounts collected under this subsection, 
     including Medicare, Medicaid, or SCHIP reimbursements under 
     titles XVIII, XIX, and XXI of the Social Security Act, shall 
     be credited to the account of the program providing the 
     service and shall be used for the purposes listed in section 
     401(d)(2) and amounts collected under this subsection shall 
     be available for expenditure within such program.
       ``(B) Indigent people.--Health services may be provided by 
     the Secretary through the Service under this subsection to an 
     indigent individual who would not be otherwise eligible for 
     such health services but for the provisions of paragraph (1) 
     only if an agreement has been entered into with a State or 
     local government under which the State or local government 
     agrees to reimburse the Service for the expenses incurred by 
     the Service in providing such health services to such 
     indigent individual.
       ``(4) Revocation of consent for services.--
       ``(A) Single tribe service area.--In the case of a Service 
     Area which serves only 1 Indian Tribe, the authority of the 
     Secretary to provide health services under paragraph (1) 
     shall terminate at the end of the fiscal year succeeding the 
     fiscal year in which the governing body of the Indian Tribe 
     revokes its concurrence to the provision of such health 
     services.
       ``(B) Multitribal service area.--In the case of a 
     multitribal Service Area, the authority of the Secretary to 
     provide health services under paragraph (1) shall terminate 
     at the end of the fiscal year succeeding the fiscal year in 
     which at least 51 percent of the number of Indian Tribes in 
     the Service Area revoke their concurrence to the provisions 
     of such health services.
       ``(d) Other Services.--The Service may provide health 
     services under this subsection to individuals who are not 
     eligible for health services provided by the Service under 
     any other provision of law in order to--
       ``(1) achieve stability in a medical emergency;
       ``(2) prevent the spread of a communicable disease or 
     otherwise deal with a public health hazard;
       ``(3) provide care to non-Indian women pregnant with an 
     eligible Indian's child for the duration of the pregnancy 
     through postpartum; or
       ``(4) provide care to immediate family members of an 
     eligible individual if such care is directly related to the 
     treatment of the eligible individual.
       ``(e) Hospital Privileges for Practitioners.--
       ``(1) In general.--Hospital privileges in health facilities 
     operated and maintained by

[[Page 27428]]

     the Service or operated under a contract or compact pursuant 
     to the Indian Self-Determination and Education Assistance Act 
     (25 U.S.C. 450 et seq.) may be extended to non-Service health 
     care practitioners who provide services to individuals 
     described in subsection (a), (b), (c), or (d). Such non-
     Service health care practitioners may, as part of the 
     privileging process, be designated as employees of the 
     Federal Government for purposes of section 1346(b) and 
     chapter 171 of title 28, United States Code (relating to 
     Federal tort claims) only with respect to acts or omissions 
     which occur in the course of providing services to eligible 
     individuals as a part of the conditions under which such 
     hospital privileges are extended.
       ``(2) Definition.--For purposes of this subsection, the 
     term `non-Service health care practitioner' means a 
     practitioner who is not--
       ``(A) an employee of the Service; or
       ``(B) an employee of an Indian tribe or tribal organization 
     operating a contract or compact under the Indian Self-
     Determination and Education Assistance Act or an individual 
     who provides health care services pursuant to a personal 
     services contract with such Indian tribe or tribal 
     organization.
       ``(f) Eligible Indian.--For purposes of this section, the 
     term `eligible Indian' means any Indian who is eligible for 
     health services provided by the Service without regard to the 
     provisions of this section.

     ``SEC. 807. REALLOCATION OF BASE RESOURCES.

       ``(a) Report Required.--Notwithstanding any other provision 
     of law, any allocation of Service funds for a fiscal year 
     that reduces by 5 percent or more from the previous fiscal 
     year the funding for any recurring program, project, or 
     activity of a Service Unit may be implemented only after the 
     Secretary has submitted to Congress, under section 801, a 
     report on the proposed change in allocation of funding, 
     including the reasons for the change and its likely effects.
       ``(b) Exception.--Subsection (a) shall not apply if the 
     total amount appropriated to the Service for a fiscal year is 
     at least 5 percent less than the amount appropriated to the 
     Service for the previous fiscal year.

     ``SEC. 808. RESULTS OF DEMONSTRATION PROJECTS.

       ``The Secretary shall provide for the dissemination to 
     Indian Tribes, Tribal Organizations, and urban Indian 
     organizations of the findings and results of demonstration 
     projects conducted under this Act.

     ``SEC. 809. MORATORIUM.

       ``During the period of the moratorium imposed on 
     implementation of the final rule published in the Federal 
     Register on September 16, 1987, by the Department of Health 
     and Human Services, relating to eligibility for the health 
     care services of the Indian Health Service, the Indian Health 
     Service shall provide services pursuant to the criteria for 
     eligibility for such services that were in effect on 
     September 15, 1987, subject to the provisions of sections 805 
     and 806, until the Service has submitted to the Committees on 
     Appropriations of the Senate and the House of Representatives 
     a budget request reflecting the increased costs associated 
     with the proposed final rule, and the request has been 
     included in an appropriations Act and enacted into law.

     ``SEC. 810. SEVERABILITY PROVISIONS.

       ``If any provision of this Act, any amendment made by the 
     Act, or the application of such provision or amendment to any 
     person or circumstances is held to be invalid, the remainder 
     of this Act, the remaining amendments made by this Act, and 
     the application of such provisions to persons or 
     circumstances other than those to which it is held invalid, 
     shall not be affected thereby.

     ``SEC. 811. USE OF PATIENT SAFETY ORGANIZATIONS.

       ``The Service, an Indian Tribe, Tribal Organization, or 
     urban Indian organization may provide for quality assurance 
     activities through the use of a patient safety organization 
     in accordance with title IX of the Public Health Service Act.

     ``SEC. 812. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE 
                   RECORDS; QUALIFIED IMMUNITY FOR PARTICIPANTS.

       ``(a) Confidentiality of Records.--Medical quality 
     assurance records created by or for any Indian Health Program 
     or a health program of an Urban Indian Organization as part 
     of a medical quality assurance program are confidential and 
     privileged. Such records may not be disclosed to any person 
     or entity, except as provided in subsection (c).
       ``(b) Prohibition on Disclosure and Testimony.--
       ``(1) In general.--No part of any medical quality assurance 
     record described in subsection (a) may be subject to 
     discovery or admitted into evidence in any judicial or 
     administrative proceeding, except as provided in subsection 
     (c).
       ``(2) Testimony.--A person who reviews or creates medical 
     quality assurance records for any Indian Health Program or 
     Urban Indian Organization who participates in any proceeding 
     that reviews or creates such records may not be permitted or 
     required to testify in any judicial or administrative 
     proceeding with respect to such records or with respect to 
     any finding, recommendation, evaluation, opinion, or action 
     taken by such person or body in connection with such records 
     except as provided in this section.
       ``(c) Authorized Disclosure and Testimony.--
       ``(1) In general.--Subject to paragraph (2), a medical 
     quality assurance record described in subsection (a) may be 
     disclosed, and a person referred to in subsection (b) may 
     give testimony in connection with such a record, only as 
     follows:
       ``(A) To a Federal executive agency or private 
     organization, if such medical quality assurance record or 
     testimony is needed by such agency or organization to perform 
     licensing or accreditation functions related to any Indian 
     Health Program or to a health program of an Urban Indian 
     Organization to perform monitoring, required by law, of such 
     program or organization.
       ``(B) To an administrative or judicial proceeding commenced 
     by a present or former Indian Health Program or Urban Indian 
     Organization provider concerning the termination, suspension, 
     or limitation of clinical privileges of such health care 
     provider.
       ``(C) To a governmental board or agency or to a 
     professional health care society or organization, if such 
     medical quality assurance record or testimony is needed by 
     such board, agency, society, or organization to perform 
     licensing, credentialing, or the monitoring of professional 
     standards with respect to any health care provider who is or 
     was an employee of any Indian Health Program or Urban Indian 
     Organization.
       ``(D) To a hospital, medical center, or other institution 
     that provides health care services, if such medical quality 
     assurance record or testimony is needed by such institution 
     to assess the professional qualifications of any health care 
     provider who is or was an employee of any Indian Health 
     Program or Urban Indian Organization and who has applied for 
     or been granted authority or employment to provide health 
     care services in or on behalf of such program or 
     organization.
       ``(E) To an officer, employee, or contractor of the Indian 
     Health Program or Urban Indian Organization that created the 
     records or for which the records were created. If that 
     officer, employee, or contractor has a need for such record 
     or testimony to perform official duties.
       ``(F) To a criminal or civil law enforcement agency or 
     instrumentality charged under applicable law with the 
     protection of the public health or safety, if a qualified 
     representative of such agency or instrumentality makes a 
     written request that such record or testimony be provided for 
     a purpose authorized by law.
       ``(G) In an administrative or judicial proceeding commenced 
     by a criminal or civil law enforcement agency or 
     instrumentality referred to in subparagraph (F), but only 
     with respect to the subject of such proceeding.
       ``(2) Identity of participants.--With the exception of the 
     subject of a quality assurance action, the identity of any 
     person receiving health care services from any Indian Health 
     Program or Urban Indian Organization or the identity of any 
     other person associated with such program or organization for 
     purposes of a medical quality assurance program that is 
     disclosed in a medical quality assurance record described in 
     subsection (a) shall be deleted from that record or document 
     before any disclosure of such record is made outside such 
     program or organization.
       ``(d) Disclosure for Certain Purposes.--
       ``(1) In general.--Nothing in this section shall be 
     construed as authorizing or requiring the withholding from 
     any person or entity aggregate statistical information 
     regarding the results of any Indian Health Program or Urban 
     Indian Organizations's medical quality assurance programs.
       ``(2) Withholding from congress.--Nothing in this section 
     shall be construed as authority to withhold any medical 
     quality assurance record from a committee of either House of 
     Congress, any joint committee of Congress, or the Government 
     Accountability Office if such record pertains to any matter 
     within their respective jurisdictions.
       ``(e) Prohibition on Disclosure of Record or Testimony.--A 
     person or entity having possession of or access to a record 
     or testimony described by this section may not disclose the 
     contents of such record or testimony in any manner or for any 
     purpose except as provided in this section.
       ``(f) Exemption From Freedom of Information Act.--Medical 
     quality assurance records described in subsection (a) may not 
     be made available to any person under section 552 of title 5, 
     United States Code.
       ``(g) Limitation on Civil Liability.--A person who 
     participates in or provides information to a person or body 
     that reviews or creates medical quality assurance records 
     described in subsection (a) shall not be civilly liable for 
     such participation or for providing such information if the 
     participation or provision of information was in good faith 
     based on prevailing professional standards at the time the 
     medical quality assurance program activity took place.
       ``(h) Application to Information in Certain Other 
     Records.--Nothing in this section shall be construed as 
     limiting access to the information in a record created and 
     maintained outside a medical quality assurance program, 
     including a patient's medical records, on the grounds that 
     the information was presented during meetings of a review

[[Page 27429]]

     body that are part of a medical quality assurance program.
       ``(i) Regulations.--The Secretary, acting through the 
     Service, shall promulgate regulations pursuant to section 
     802.
       ``(j) Definitions.--In this section:
       ``(1) The term `health care provider' means any health care 
     professional, including community health aides and 
     practitioners certified under section 121, who are granted 
     clinical practice privileges or employed to provide health 
     care services in an Indian Health Program or health program 
     of an Urban Indian Organization, who is licensed or certified 
     to perform health care services by a governmental board or 
     agency or professional health care society or organization.
       ``(2) The term `medical quality assurance program' means 
     any activity carried out before, on, or after the date of 
     enactment of this Act by or for any Indian Health Program or 
     Urban Indian Organization to assess the quality of medical 
     care, including activities conducted by or on behalf of 
     individuals, Indian Health Program or Urban Indian 
     Organization medical or dental treatment review committees, 
     or other review bodies responsible for quality assurance, 
     credentials, infection control, patient safety, patient care 
     assessment (including treatment procedures, blood, drugs, and 
     therapeutics), medical records, health resources management 
     review and identification and prevention of medical or dental 
     incidents and risks.
       ``(3) The term `medical quality assurance record' means the 
     proceedings, records, minutes, and reports that emanate from 
     quality assurance program activities described in paragraph 
     (2) and are produced or compiled by or for an Indian Health 
     Program or Urban Indian Organization as part of a medical 
     quality assurance program.
       ``(k) Continued Protection.--Disclosure under subsection 
     (c) does not permit redisclosure except to the extent such 
     further disclosure is authorized under subsection (c) or is 
     otherwise authorized to be disclosed under this section.
       ``(l) Inconsistencies.--To the extent that the protections 
     under the Patient Safety and Quality Improvement Act of 2005 
     and this section are inconsistent, the provisions of 
     whichever is more protective shall control.
       ``(m) Relationship to Other Law.--This section shall 
     continue in force and effect, except as otherwise 
     specifically provided in any Federal law enacted after the 
     date of enactment of the Indian Health Care Improvement Act 
     Amendments of 2009.

     ``SEC. 813. CLAREMORE INDIAN HOSPITAL.

       ``The Claremore Indian Hospital shall be deemed to be a 
     dependant Indian community for the purposes of section 1151 
     of title 18, United States Code.

     ``SEC. 814. SENSE OF CONGRESS REGARDING LAW ENFORCEMENT AND 
                   METHAMPHETAMINE ISSUES IN INDIAN COUNTRY.

       ``It is the sense of Congress that Congress encourages 
     State, local, and Indian tribal law enforcement agencies to 
     enter into memoranda of agreement between and among those 
     agencies for purposes of streamlining law enforcement 
     activities and maximizing the use of limited resources--
       ``(1) to improve law enforcement services provided to 
     Indian tribal communities; and
       ``(2) to increase the effectiveness of measures to address 
     problems relating to methamphetamine use in Indian country 
     (as defined in section 1151 of title 18, United States Code).

     ``SEC. 815. PERMITTING IMPLEMENTATION THROUGH CONTRACTS WITH 
                   TRIBAL HEALTH PROGRAMS.

       ``Nothing in this Act shall be construed as preventing the 
     Secretary from--
       ``(1) carrying out any section of this Act through 
     contracts with Tribal Health Programs; and
       ``(2) carrying out sections through 214, 701(a)(1), 
     701(b)(1), 701(c), 707(g), and 712(b), through contracts with 
     urban Indian organizations.
     The previous sentence shall not affect the authority the 
     Secretary may otherwise have to carry out other provisions of 
     this Act through such contracts.

     ``SEC. 816. AUTHORIZATION OF APPROPRIATIONS; AVAILABILITY.

       ``(a) Authorization of Appropriations.--There are 
     authorized to be appropriated such sums as may be necessary 
     to carry out this title.
       ``(b) Limitation on New Spending Authority.--Any new 
     spending authority (described in subparagraph (A) or (B) of 
     section 401(c)(2) of the Congressional Budget Act of 1974 
     (Public Law 93-344; 88 Stat. 317)) which is provided under 
     this Act shall be effective for any fiscal year only to such 
     extent or in such amounts as are provided in appropriation 
     Acts.
       ``(c) Availability.--The funds appropriated pursuant to 
     this Act shall remain available until expended.''.
       (b) Rate of Pay.--
       (1) Positions at level iv.--Section 5315 of title 5, United 
     States Code, is amended by striking ``Assistant Secretaries 
     of Health and Human Services (6).'' and inserting ``Assistant 
     Secretaries of Health and Human Services (7)''.
       (2) Positions at level v.--Section 5316 of title 5, United 
     States Code, is amended by striking ``Director, Indian Health 
     Service, Department of Health and Human Services''.
       (c) Amendments to Other Provisions of Law.--
       (1) Section 3307(b)(1)(C) of the Children's Health Act of 
     2000 (25 U.S.C. 1671 note; Public Law 106-310) is amended by 
     striking ``Director of the Indian Health Service'' and 
     inserting ``Assistant Secretary for Indian Health''.
       (2) The Indian Lands Open Dump Cleanup Act of 1994 is 
     amended--
       (A) in section 3 (25 U.S.C. 3902)--
       (i) by striking paragraph (2);
       (ii) by redesignating paragraphs (1), (3), (4), (5), and 
     (6) as paragraphs (4), (5), (2), (6), and (1), respectively, 
     and moving those paragraphs so as to appear in numerical 
     order; and
       (iii) by inserting before paragraph (4) (as redesignated by 
     subclause (II)) the following:
       ``(3) Assistant secretary.--The term `Assistant Secretary' 
     means the Assistant Secretary for Indian Health.'';
       (B) in section 5 (25 U.S.C. 3904), by striking the section 
     designation and heading and inserting the following:

     ``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN 
                   HEALTH.'';

       (C) in section 6(a) (25 U.S.C. 3905(a)), in the subsection 
     heading, by striking ``Director'' and inserting ``Assistant 
     Secretary'';
       (D) in section 9(a) (25 U.S.C. 3908(a)), in the subsection 
     heading, by striking ``Director'' and inserting ``Assistant 
     Secretary''; and
       (E) by striking ``Director'' each place it appears and 
     inserting ``Assistant Secretary''.
       (3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T. 
     Stafford Elementary and Secondary School Improvement 
     Amendments of 1988 (25 U.S.C. 2001 note; Public Law 100-297) 
     is amended by striking ``Director of the Indian Health 
     Service'' and inserting ``Assistant Secretary for Indian 
     Health''.
       (4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29 
     U.S.C. 763(a)(1)) is amended by striking ``Director of the 
     Indian Health Service'' and inserting ``Assistant Secretary 
     for Indian Health''.
       (5) Subsections (b) and (e) of section 518 of the Federal 
     Water Pollution Control Act (33 U.S.C. 1377) are amended by 
     striking ``Director of the Indian Health Service'' each place 
     it appears and inserting ``Assistant Secretary for Indian 
     Health''.
       (6) Section 317M(b) of the Public Health Service Act (42 
     U.S.C. 247b-14(b)) is amended--
       (A) by striking ``Director of the Indian Health Service'' 
     each place it appears and inserting ``Assistant Secretary for 
     Indian Health''; and
       (B) in paragraph (2)(A), by striking ``the Directors 
     referred to in such paragraph'' and inserting ``the Director 
     of the Centers for Disease Control and Prevention and the 
     Assistant Secretary for Indian Health''.
       (7) Section 417C(b) of the Public Health Service Act (42 
     U.S.C. 285-9(b)) is amended by striking ``Director of the 
     Indian Health Service'' and inserting ``Assistant Secretary 
     for Indian Health''.
       (8) Section 1452(i) of the Safe Drinking Water Act (42 
     U.S.C. 300j-12(i)) is amended by striking ``Director of the 
     Indian Health Service'' each place it appears and inserting 
     ``Assistant Secretary for Indian Health''.
       (9) Section 803B(d)(1) of the Native American Programs Act 
     of 1974 (42 U.S.C. 2991b-2(d)(1)) is amended in the last 
     sentence by striking ``Director of the Indian Health 
     Service'' and inserting ``Assistant Secretary for Indian 
     Health''.
       (10) Section 203(b) of the Michigan Indian Land Claims 
     Settlement Act (Public Law 105-143; 111 Stat. 2666) is 
     amended by striking ``Director of the Indian Health Service'' 
     and inserting ``Assistant Secretary for Indian Health''.

     SEC. 3102. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

       (a) In General.--The Indian Self-Determination and 
     Education Assistance Act (25 U.S.C. 450 et seq.) is amended 
     by adding at the end the following:

      ``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION

     ``SEC. 801. DEFINITIONS.

       ``In this title:
       ``(1) Board.--The term `Board' means the Board of Directors 
     of the Foundation.
       ``(2) Committee.--The term `Committee' means the Committee 
     for the Establishment of Native American Health and Wellness 
     Foundation established under section 802(f).
       ``(3) Foundation.--The term `Foundation' means the Native 
     American Health and Wellness Foundation established under 
     section 802.
       ``(4) Secretary.--The term `Secretary' means the Secretary 
     of Health and Human Services.
       ``(5) Service.--The term `Service' means the Indian Health 
     Service of the Department of Health and Human Services.

     ``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

       ``(a) Establishment.--
       ``(1) In general.--As soon as practicable after the date of 
     enactment of this title, the Secretary shall establish, under 
     the laws of the District of Columbia and in accordance with 
     this title, the Native American Health and Wellness 
     Foundation.
       ``(2) Funding determinations.--No funds, gift, property, or 
     other item of value (including any interest accrued on such 
     an item) acquired by the Foundation shall--
       ``(A) be taken into consideration for purposes of 
     determining Federal appropriations

[[Page 27430]]

     relating to the provision of health care and services to 
     Indians; or
       ``(B) otherwise limit, diminish, or affect the Federal 
     responsibility for the provision of health care and services 
     to Indians.
       ``(b) Perpetual Existence.--The Foundation shall have 
     perpetual existence.
       ``(c) Nature of Corporation.--The Foundation--
       ``(1) shall be a charitable and nonprofit federally 
     chartered corporation; and
       ``(2) shall not be an agency or instrumentality of the 
     United States.
       ``(d) Place of Incorporation and Domicile.--The Foundation 
     shall be incorporated and domiciled in the District of 
     Columbia.
       ``(e) Duties.--The Foundation shall--
       ``(1) encourage, accept, and administer private gifts of 
     real and personal property, and any income from or interest 
     in such gifts, for the benefit of, or in support of, the 
     mission of the Service;
       ``(2) undertake and conduct such other activities as will 
     further the health and wellness activities and opportunities 
     of Native Americans; and
       ``(3) participate with and assist Federal, State, and 
     tribal governments, agencies, entities, and individuals in 
     undertaking and conducting activities that will further the 
     health and wellness activities and opportunities of Native 
     Americans.
       ``(f) Committee for the Establishment of Native American 
     Health and Wellness Foundation.--
       ``(1) In general.--The Secretary shall establish the 
     Committee for the Establishment of Native American Health and 
     Wellness Foundation to assist the Secretary in establishing 
     the Foundation.
       ``(2) Duties.--Not later than 180 days after the date of 
     enactment of this section, the Committee shall--
       ``(A) carry out such activities as are necessary to 
     incorporate the Foundation under the laws of the District of 
     Columbia, including acting as incorporators of the 
     Foundation;
       ``(B) ensure that the Foundation qualifies for and 
     maintains the status required to carry out this section, 
     until the Board is established;
       ``(C) establish the constitution and initial bylaws of the 
     Foundation;
       ``(D) provide for the initial operation of the Foundation, 
     including providing for temporary or interim quarters, 
     equipment, and staff; and
       ``(E) appoint the initial members of the Board in 
     accordance with the constitution and initial bylaws of the 
     Foundation.
       ``(g) Board of Directors.--
       ``(1) In general.--The Board of Directors shall be the 
     governing body of the Foundation.
       ``(2) Powers.--The Board may exercise, or provide for the 
     exercise of, the powers of the Foundation.
       ``(3) Selection.--
       ``(A) In general.--Subject to subparagraph (B), the number 
     of members of the Board, the manner of selection of the 
     members (including the filling of vacancies), and the terms 
     of office of the members shall be as provided in the 
     constitution and bylaws of the Foundation.
       ``(B) Requirements.--
       ``(i) Number of members.--The Board shall have at least 11 
     members, who shall have staggered terms.
       ``(ii) Initial voting members.--The initial voting members 
     of the Board--

       ``(I) shall be appointed by the Committee not later than 
     180 days after the date on which the Foundation is 
     established; and
       ``(II) shall have staggered terms.

       ``(iii) Qualification.--The members of the Board shall be 
     United States citizens who are knowledgeable or experienced 
     in Native American health care and related matters.
       ``(C) Compensation.--A member of the Board shall not 
     receive compensation for service as a member, but shall be 
     reimbursed for actual and necessary travel and subsistence 
     expenses incurred in the performance of the duties of the 
     Foundation.
       ``(h) Officers.--
       ``(1) In general.--The officers of the Foundation shall 
     be--
       ``(A) a secretary, elected from among the members of the 
     Board; and
       ``(B) any other officers provided for in the constitution 
     and bylaws of the Foundation.
       ``(2) Chief operating officer.--The secretary of the 
     Foundation may serve, at the direction of the Board, as the 
     chief operating officer of the Foundation, or the Board may 
     appoint a chief operating officer, who shall serve at the 
     direction of the Board.
       ``(3) Election.--The manner of election, term of office, 
     and duties of the officers of the Foundation shall be as 
     provided in the constitution and bylaws of the Foundation.
       ``(i) Powers.--The Foundation--
       ``(1) shall adopt a constitution and bylaws for the 
     management of the property of the Foundation and the 
     regulation of the affairs of the Foundation;
       ``(2) may adopt and alter a corporate seal;
       ``(3) may enter into contracts;
       ``(4) may acquire (through a gift or otherwise), own, 
     lease, encumber, and transfer real or personal property as 
     necessary or convenient to carry out the purposes of the 
     Foundation;
       ``(5) may sue and be sued; and
       ``(6) may perform any other act necessary and proper to 
     carry out the purposes of the Foundation.
       ``(j) Principal Office.--
       ``(1) In general.--The principal office of the Foundation 
     shall be in the District of Columbia.
       ``(2) Activities; offices.--The activities of the 
     Foundation may be conducted, and offices may be maintained, 
     throughout the United States in accordance with the 
     constitution and bylaws of the Foundation.
       ``(k) Service of Process.--The Foundation shall comply with 
     the law on service of process of each State in which the 
     Foundation is incorporated and of each State in which the 
     Foundation carries on activities.
       ``(l) Liability of Officers, Employees, and Agents.--
       ``(1) In general.--The Foundation shall be liable for the 
     acts of the officers, employees, and agents of the Foundation 
     acting within the scope of their authority.
       ``(2) Personal liability.--A member of the Board shall be 
     personally liable only for gross negligence in the 
     performance of the duties of the member.
       ``(m) Restrictions.--
       ``(1) Limitation on spending.--Beginning with the fiscal 
     year following the first full fiscal year during which the 
     Foundation is in operation, the administrative costs of the 
     Foundation shall not exceed the percentage described in 
     paragraph (2) of the sum of--
       ``(A) the amounts transferred to the Foundation under 
     subsection (o) during the preceding fiscal year; and
       ``(B) donations received from private sources during the 
     preceding fiscal year.
       ``(2) Percentages.--The percentages referred to in 
     paragraph (1) are--
       ``(A) for the first fiscal year described in that 
     paragraph, 20 percent;
       ``(B) for the following fiscal year, 15 percent; and
       ``(C) for each fiscal year thereafter, 10 percent.
       ``(3) Appointment and hiring.--The appointment of officers 
     and employees of the Foundation shall be subject to the 
     availability of funds.
       ``(4) Status.--A member of the Board or officer, employee, 
     or agent of the Foundation shall not by reason of association 
     with the Foundation be considered to be an officer, employee, 
     or agent of the United States.
       ``(n) Audits.--The Foundation shall comply with section 
     10101 of title 36, United States Code, as if the Foundation 
     were a corporation under part B of subtitle II of that title.
       ``(o) Funding.--
       ``(1) Authorization of appropriations.--There is authorized 
     to be appropriated to carry out subsection (e)(1) $500,000 
     for each fiscal year, as adjusted to reflect changes in the 
     Consumer Price Index for all-urban consumers published by the 
     Department of Labor.
       ``(2) Transfer of donated funds.--The Secretary shall 
     transfer to the Foundation funds held by the Department of 
     Health and Human Services under the Act of August 5, 1954 (42 
     U.S.C. 2001 et seq.), if the transfer or use of the funds is 
     not prohibited by any term under which the funds were 
     donated.

     ``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.

       ``(a) Provision of Support by Secretary.--Subject to 
     subsection (b), during the 5-year period beginning on the 
     date on which the Foundation is established, the Secretary--
       ``(1) may provide personnel, facilities, and other 
     administrative support services to the Foundation;
       ``(2) may provide funds for initial operating costs and to 
     reimburse the travel expenses of the members of the Board; 
     and
       ``(3) shall require and accept reimbursements from the 
     Foundation for--
       ``(A) services provided under paragraph (1); and
       ``(B) funds provided under paragraph (2).
       ``(b) Reimbursement.--Reimbursements accepted under 
     subsection (a)(3)--
       ``(1) shall be deposited in the Treasury of the United 
     States to the credit of the applicable appropriations 
     account; and
       ``(2) shall be chargeable for the cost of providing 
     services described in subsection (a)(1) and travel expenses 
     described in subsection (a)(2).
       ``(c) Continuation of Certain Services.--The Secretary may 
     continue to provide facilities and necessary support services 
     to the Foundation after the termination of the 5-year period 
     specified in subsection (a) if the facilities and services--
       ``(1) are available; and
       ``(2) are provided on reimbursable cost basis.''.
       (b) Technical Amendments.--The Indian Self-Determination 
     and Education Assistance Act is amended--
       (1) by redesignating title V (25 U.S.C. 458bbb et seq.) as 
     title VII;
       (2) by redesignating sections 501, 502, and 503 (25 U.S.C. 
     458bbb, 458bbb-1, 458bbb-2) as sections 701, 702, and 703, 
     respectively; and
       (3) in subsection (a)(2) of section 702 and paragraph (2) 
     of section 703 (as redesignated by paragraph (2)), by 
     striking ``section 501'' and inserting ``section 701''.

     SEC. 3103. GAO STUDY AND REPORT ON PAYMENTS FOR CONTRACT 
                   HEALTH SERVICES.

       (a) Study.--

[[Page 27431]]

       (1) In general.--The Comptroller General of the United 
     States (in this section referred to as the ``Comptroller 
     General'') shall conduct a study on the utilization of health 
     care furnished by health care providers under the contract 
     health services program funded by the Indian Health Service 
     and operated by the Indian Health Service, an Indian Tribe, 
     or a Tribal Organization (as those terms are defined in 
     section 4 of the Indian Health Care Improvement Act).
       (2) Analysis.--The study conducted under paragraph (1) 
     shall include an analysis of--
       (A) the amounts reimbursed under the contract health 
     services program described in paragraph (1) for health care 
     furnished by entities, individual providers, and suppliers, 
     including a comparison of reimbursement for such health care 
     through other public programs and in the private sector;
       (B) barriers to accessing care under such contract health 
     services program, including, but not limited to, barriers 
     relating to travel distances, cultural differences, and 
     public and private sector reluctance to furnish care to 
     patients under such program;
       (C) the adequacy of existing Federal funding for health 
     care under such contract health services program; and
       (D) any other items determined appropriate by the 
     Comptroller General.
       (b) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Comptroller General shall submit 
     to Congress a report on the study conducted under subsection 
     (a), together with recommendations regarding--
       (1) the appropriate level of Federal funding that should be 
     established for health care under the contract health 
     services program described in subsection (a)(1); and
       (2) how to most efficiently utilize such funding.
       (c) Consultation.--In conducting the study under subsection 
     (a) and preparing the report under subsection (b), the 
     Comptroller General shall consult with the Indian Health 
     Service, Indian Tribes, and Tribal Organizations.

 TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL 
                              SECURITY ACT

     SEC. 3201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID, 
                   AND SCHIP FOR ALL COVERED SERVICES FURNISHED BY 
                   INDIAN HEALTH PROGRAMS.

       (a) Medicaid.--
       (1) Expansion to all covered services.--Section 1911 of the 
     Social Security Act (42 U.S.C. 1396j) is amended--
       (A) by amending the heading to read as follows:

     ``SEC. 1911. INDIAN HEALTH PROGRAMS.'';

     and
       (B) by amending subsection (a) to read as follows:
       ``(a) Eligibility for Payment for Medical Assistance.--An 
     Indian Health Program shall be eligible for payment for 
     medical assistance provided under a State plan or under 
     waiver authority with respect to items and services furnished 
     by the Program if the furnishing of such services meets all 
     the conditions and requirements which are applicable 
     generally to the furnishing of items and services under this 
     title and under such plan or waiver authority.''.
       (2) Repeal of obsolete provision.--Subsection (b) of such 
     section is repealed.
       (3) Revision of authority to enter into agreements.--
     Subsection (c) of such section is amended to read as follows:
       ``(c) Authority To Enter Into Agreements.--The Secretary 
     may enter into an agreement with a State for the purpose of 
     reimbursing the State for medical assistance provided by the 
     Indian Health Service, an Indian Tribe, Tribal Organization, 
     or an Urban Indian Organization (as so defined), directly, 
     through referral, or under contracts or other arrangements 
     between the Indian Health Service, an Indian Tribe, Tribal 
     Organization, or an Urban Indian Organization and another 
     health care provider to Indians who are eligible for medical 
     assistance under the State plan or under waiver authority. 
     This subsection shall not be construed to impair the 
     entitlement of a State to reimbursement for such medical 
     assistance under this title.''.
       (4) Cross-references to special fund for improvement of ihs 
     facilities; direct billing option; definitions.--Such section 
     is further amended by striking subsection (d) and adding at 
     the end the following new subsections:
       ``(c) Special Fund for Improvement of IHS Facilities.--For 
     provisions relating to the authority of the Secretary to 
     place payments to which a facility of the Indian Health 
     Service is eligible for payment under this title into a 
     special fund established under section 401(c)(1) of the 
     Indian Health Care Improvement Act, see subparagraphs (A) and 
     (B) of section 401(c)(1) of such Act.
       ``(d) Direct Billing.--For provisions relating to the 
     authority of an Tribal Health Program to elect to directly 
     bill for, and receive payment for, health care items and 
     services provided by such Program for which payment is made 
     under this title, see section 401(d) of the Indian Health 
     Care Improvement Act.''.
       (5) Definitions.--Section 1101(a) of such Act (42 U.S.C. 
     1301(a)) is amended by adding at the end the following new 
     paragraph:
       ``(11) For purposes of this title and titles XVIII, XIX, 
     and XXI, the terms `Indian Health Program', `Indian Tribe' 
     (and `Indian tribe'), `Tribal Health Program', `Tribal 
     Organization' (and `tribal organization'), and `urban Indian 
     organization' (and `urban Indian organization') have the 
     meanings given those terms in section 4 of the Indian Health 
     Care Improvement Act.''.
       (b) Medicare.--
       (1) Expansion to all covered services.--Section 1880 of 
     such Act (42 U.S.C. 1395qq) is amended--
       (A) by amending the heading to read as follows:

     ``SEC. 1880. INDIAN HEALTH PROGRAMS.'';

     and
       (B) by amending subsection (a) to read as follows:
       ``(a) Eligibility for Payments.--Subject to subsection (e), 
     an Indian Health Program shall be eligible for payments under 
     this title with respect to items and services furnished by 
     the Program if the furnishing of such services meets all the 
     conditions and requirements which are applicable generally to 
     the furnishing of items and services under this title.''.
       (2) Repeal of obsolete provision.--Subsection (b) of such 
     section is repealed.
       (3) Cross-references to special fund for improvement of ihs 
     facilities; direct billing option; definitions.--
       (A) In general.--Such section is further amended by 
     striking subsections (c) and (d) and inserting the following 
     new subsections:
       ``(b) Special Fund for Improvement of IHS Facilities.--For 
     provisions relating to the authority of the Secretary to 
     place payments to which a facility of the Indian Health 
     Service is eligible for payment under this title into a 
     special fund established under section 401(c)(1) of the 
     Indian Health Care Improvement Act, and the requirement to 
     use amounts paid from such fund for making improvements in 
     accordance with subsection (b), see subparagraphs (A) and (B) 
     of section 401(c)(1) of such Act.
       ``(c) Direct Billing.--For provisions relating to the 
     authority of a Tribal Health Program to elect to directly 
     bill for, and receive payment for, health care items and 
     services provided by such Program for which payment is made 
     under this title, see section 401(d) of the Indian Health 
     Care Improvement Act.''.
       (B) Conforming amendments.--Such section is further 
     amended--
       (i) in subsection (e)(3), by striking ``Subsection (c)'' 
     and inserting ``Subsection (b) and section 401(b)(1) of the 
     Indian Health Care Improvement Act'';
       (ii) by redesignating subsection (e) as subsection (d); and
       (iii) by striking subsection (f).
       (4) Definitions.--Such section is further amended by 
     amending adding at the end the following new subsection:
       ``(e) Definitions.--In this section, the terms `Indian 
     Health Program', `Indian Tribe', `Service Unit', `Tribal 
     Health Program', `Tribal Organization', and `Urban Indian 
     Organization' have the meanings given those terms in section 
     4 of the Indian Health Care Improvement Act.''.
       (c) Application to SCHIP.--Section 2107(e)(1) of the Social 
     Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
       (1) by redesignating subparagraphs (K) through (M) as 
     subparagraphs (L) through (N), respectively; and
       (2) by inserting after subparagraph (J), the following new 
     subparagraph:
       ``(K) Section 1911 (relating to Indian Health Programs, 
     other than subsection (c) of such section).''.

     SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND 
                   ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID.

       (a) Assurance of Payments to Indian Health Care Providers 
     for Child Health Assistance.--Section 2102(b)(3)(D) of the 
     Social Security Act (42 U.S.C. 1397bb(b)(3)(D)) is amended by 
     striking ``(as defined in section 4(c) of the Indian Health 
     Care Improvement Act, 25 U.S.C. 1603(c))'' and inserting ``, 
     including how the State will ensure that payments are made to 
     Indian Health Programs and urban Indian organizations 
     operating in the State for the provision of such 
     assistance''.
       (b) Inclusion of Other Indian Financed Health Care Programs 
     in Exemption From Prohibition on Certain Payments.--Section 
     2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B)) is 
     amended by striking ``insurance program, other than an 
     insurance program operated or financed by the Indian Health 
     Service'' and inserting ``program, other than a health care 
     program operated or financed by the Indian Health Service or 
     by an Indian Tribe, Tribal Organization, or urban Indian 
     organization''.
       (c) Definitions.--Section 2110(c) of such Act (42 U.S.C. 
     1397jj(c)) is amended by adding at the end the following new 
     paragraph:
       ``(9) Indian; indian health program; indian tribe; etc.--
     The terms `Indian', `Indian Health Program', `Indian Tribe', 
     `Tribal Organization', and `Urban Indian Organization' have 
     the meanings given those terms in section 4 of the Indian 
     Health Care Improvement Act.''.

[[Page 27432]]



     SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HARBORS UNDER 
                   THE SOCIAL SECURITY ACT FOR FACILITIES OF 
                   INDIAN HEALTH PROGRAMS AND URBAN INDIAN 
                   ORGANIZATIONS.

       The Secretary of Health and Human Services, acting through 
     the Office of the Inspector General of the Department of 
     Health and Human Services, shall publish a notice, described 
     in section 1128D(a)(1)(A) of the Social Security Act (42 
     U.S.C. 1320a-7d(a)(1)(A)), soliciting a proposal, not later 
     than July 1, 2010, on the development of safe harbors 
     described in such section relating to health care items and 
     services provided by facilities of Indian Health Programs or 
     an urban Indian organization (as such terms are defined in 
     section 4 of the Indian Health Care Improvement Act). Such a 
     safe harbor may relate to areas such as transportation, 
     housing, or cost-sharing, assistance provided through such 
     facilities or contract health services for Indians.

     SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY 
                   ACT HEALTH BENEFIT PROGRAMS.

       Section 1139 of the Social Security Act (42 U.S.C. 1320b-
     9), as amended by the sections 3203 and 3204, is amended by 
     redesignating subsection (e) as subsection (f), and inserting 
     after subsection (d) the following new subsection:
       ``(e) Annual Report on Indians Served by Health Benefit 
     Programs Funded Under This Act.--Beginning January 1, 2011, 
     and annually thereafter, the Secretary, acting through the 
     Administrator of the Centers for Medicare & Medicaid Services 
     and the Director of the Indian Health Service, shall submit a 
     report to Congress regarding the enrollment and health status 
     of Indians receiving items or services under health benefit 
     programs funded under this Act during the preceding year. 
     Each such report shall include the following:
       ``(1) The total number of Indians enrolled in, or receiving 
     items or services under, such programs, disaggregated with 
     respect to each such program.
       ``(2) The number of Indians described in paragraph (1) that 
     also received health benefits under programs funded by the 
     Indian Health Service.
       ``(3) General information regarding the health status of 
     the Indians described in paragraph (1), disaggregated with 
     respect to specific diseases or conditions and presented in a 
     manner that is consistent with protections for privacy of 
     individually identifiable health information under section 
     264(c) of the Health Insurance Portability and Accountability 
     Act of 1996.
       ``(4) A detailed statement of the status of facilities of 
     the Indian Health Service or an Indian Tribe, Tribal 
     Organization, or an Urban Indian Organization with respect to 
     such facilities' compliance with the applicable conditions 
     and requirements of titles XVIII, XIX, and XXI, and, in the 
     case of title XIX or XXI, under a State plan under such title 
     or under waiver authority, and of the progress being made by 
     such facilities (under plans submitted under 1911(b) or 
     otherwise) toward the achievement and maintenance of such 
     compliance.
       ``(5) Such other information as the Secretary determines is 
     appropriate.''.

     SEC. 3205. DEVELOPMENT OF RECOMMENDATIONS TO IMPROVE 
                   INTERSTATE COORDINATION OF MEDICAID AND SCHIP 
                   COVERAGE OF INDIAN CHILDREN AND OTHER CHILDREN 
                   WHO ARE OUTSIDE OF THEIR STATE OF RESIDENCY 
                   BECAUSE OF EDUCATIONAL OR OTHER NEEDS.

       (a) Study.--The Secretary shall conduct a study to identify 
     barriers to interstate coordination of enrollment and 
     coverage under the Medicaid program under title XIX of the 
     Social Security Act and the State Children's Health Insurance 
     Program under title XXI of such Act of children who are 
     eligible for medical assistance or child health assistance 
     under such programs and who, because of educational needs, 
     migration of families, emergency evacuations, or otherwise, 
     frequently change their State of residency or otherwise are 
     temporarily present outside of the State of their residency. 
     Such study shall include an examination of the enrollment and 
     coverage coordination issues faced by Indian children who are 
     eligible for medical assistance or child health assistance 
     under such programs in their State of residence and who 
     temporarily reside in an out-of-State boarding school or 
     peripheral dormitory funded by the Bureau of Indian Affairs.
       (b) Report.--Not later than 18 months after the date of 
     enactment of this Act, the Secretary, in consultation with 
     directors of State Medicaid programs under title XIX of the 
     Social Security Act and directors of State Children's Health 
     Insurance Programs under title XXI of such Act, shall submit 
     a report to Congress that contains recommendations for such 
     legislative and administrative actions as the Secretary 
     determines appropriate to address the enrollment and coverage 
     coordination barriers identified through the study required 
     under subsection (a).
  The SPEAKER pro tempore. After 4 hours of debate on the bill, as 
amended, equally divided among and controlled by the Chair and ranking 
minority member of the Committee on Energy and Commerce, the Chair and 
ranking minority member of the Committee on Ways and Means, and the 
Chair and ranking minority member of the Committee on Education and 
Labor, the further amendment printed in part C of the report, if 
offered by the gentleman from Michigan (Mr. Stupak) or his designee, 
shall be considered read, and shall be debatable for 20 minutes, 
equally divided and controlled by the proponent and an opponent. The 
further amendment in the nature of a substitute printed in part D of 
the report, if offered by the gentleman from Ohio (Mr. Boehner) or his 
designee, shall be considered as read, and shall be debatable for 1 
hour equally divided and controlled by the proponent and an opponent.
  The gentleman from California (Mr. Waxman), the gentleman from Texas 
(Mr. Barton), the gentleman from New York (Mr. Rangel), the gentleman 
from Michigan (Mr. Camp), the gentleman from California (Mr. George 
Miller), and the gentleman from Minnesota (Mr. Kline) each will control 
40 minutes.
  The Chair now recognizes the gentleman from California (Mr. Waxman).

                              {time}  1400

  Mr. WAXMAN. Mr. Speaker, I am pleased to start off the debate by 
recognizing our very distinguished majority leader, Steny Hoyer from 
the State of Maryland, for 1 minute.
  Mr. HOYER. I thank Mr. Waxman for yielding.
  Our rule was chaired by John Dingell, himself a historic figure on a 
historic day.
  I want to congratulate all of those who have participated in the 
accomplishment of the product that we consider this day: Mr. Waxman, 
one of our senior Members in the House; Mr. Rangel, one of our senior 
Members in the House; and Mr. Miller.
  I want to thank too the Republicans who engaged in this discussion, 
in this debate, because it is historic, and all of us who sit in this 
Chamber know that it will have a great effect on our people. Some 
perceive that effect as not positive. More, I believe, think it is 
positive. In any event, none of us believe that it is not 
extraordinarily important.
  Soon each one of us is going to look into his or her conscience and 
vote on this bill. And when the time comes, I don't know if any words 
of mine will sway any of you. But I know that the most powerful 
arguments for the bill won't be spoken on this floor. They are being 
lived right now in our country in every one of our districts, in every 
one of our towns and counties and municipalities.
  In the anxiety of the family that finds itself paying more and more 
each year for health insurance that grows weaker and weaker.
  In the frustration of the small business owner weighing the choices 
of dropping her employees' coverage against the threat of being driven 
out of business by her competitors.
  And in the fury of the patient who learns that an insurance company 
bureaucrat has deemed him too sick for the coverage he paid for.
  They are our families, our neighbors, our fellow citizens. They are 
waiting for health insurance reform that is more affordable, more 
secure, more just. Their stories will be with me and I know with each 
of us when we cast our vote.
  Because I want to say to every American facing down illness: never 
again, never again will you be denied coverage because you have 
diabetes or asthma or some other disease or because you're pregnant or 
because you have anything else your insurer decides is a preexisting 
condition. Never again will your coverage run out. Nor will you find 
the coverage you thought you had paid for was actually not there at 
all. And never again can insurance companies drive out competition and 
set premiums as high as they like, because there will be a public 
insurance option and a transparent marketplace to keep them honest, to 
keep them competitive, to bring prices down.
  I want to say to our middle class families, the backbone of our 
country: you will have coverage that you can depend upon. Even if you 
change your job or lose your job or decide to start a business, you 
will be able to find affordable coverage in a competitive

[[Page 27433]]

marketplace, an insurance exchange that offers you a choice of good 
policies at fair rates. In fact, according to an MIT analysis, buying 
coverage on the exchange will bring your premiums down by a great deal, 
even without the affordability credits.
  If your family makes $90,000 or more, you'll save more than 1,200 
bucks. If your family makes $60,000, you'll save more than $5,000. And 
if your family is making $38,000, you'll save more than $9,000. That's 
the kind of tax cut that America needs to secure its medical future.
  I want to say to our seniors: you can count on Medicare, on a Federal 
program, for dignity and peace of mind in your golden years. And that 
will not change. Today we will vote to protect your access to your 
doctor, to encourage Medicare physicians to cooperate on higher quality 
care, to keep your Medicare solvent for longer, and to bring an end to 
the doughnut hole that leaves prescription drugs unaffordable for so 
many.
  I want to say to our small businessmen and women: I know your 
premiums keep going up and that each year they make it harder to stay 
in business, to compete with Big Business and with foreign firms. You 
deserve a fair playing field; and in the insurance exchange 
marketplace, you'll be able to buy coverage at the low group rates 
you're now being denied.
  I want to say to the 35 million Americans without insurance, who are 
forced to skip checkups and preventative care, who are forced to turn 
to the ER as the first and only line of defense, who live sicker and 
shorter lives: you will have what every man, woman, and child has in 
every other industrialized country in the world: health coverage you 
can afford and that you can count on.
  And every American who is rightly worried about our mounting deficits 
and debt, I can tell you this: this bill does not add to the deficit 
over the next 10 years or the 10 years thereafter. This bill means 
health care that is more fiscally sustainable for years to come.
  That is what this bill, the Affordable Health Care for America Act, 
can achieve for our country and for our people. It isn't a simple bill. 
It isn't a perfect bill, but it is the product of months and months of 
careful debate, sometimes animated debate, yes, even angry debate, 
careful scrutiny, hard work, and citizen input. And it's the right 
response to this time of economic insecurity in which we have been 
called to lead.
  If we miss this chance, or if we vote for a Republican plan that does 
very little to expand coverage, weakens insurance, frankly, for 
millions who have it, and continues to allow millions of Americans to 
be denied affordable coverage, we'll find ourselves back here again.
  But by then, premiums will eat up even more of our families' budgets; 
health care will consume even more of our economy; and even more 
Americans will have died for the lack of health care.
  If we miss this chance, if we miss this challenge of nearly a 
century's duration, when Teddy Roosevelt, one of the great Presidents 
of this country, a Republican President of this country, said a hundred 
years ago we need to have health care coverage for all Americans--this 
is not a new idea, but it is an idea whose time has surely come--the 
years between this chance and our next one will be filled with stories 
that are unworthy of America at its best.
  Stories like Linda's, who wrote to The New York Times of the anguish 
she felt suffering from abdominal cancer and standing in the hospital 
just feet away from the drugs that could help save her life, drugs her 
insurance company was denying her.
  Stories like Deamonte Driver's from Prince George's County, just a 
few miles down the road, who died at the age of 12 from a toothache, a 
toothache that was not treated by a dentist; and, as a result, it 
became infected. That infection went into his brain. He was in the 
hospital for 30 days at a cost of $250,000. Why? Because he didn't have 
$80 to get that tooth filled.
  This bill will change that. We can be better than that. America is 
better than that. We must be.
  Americans rightly want to know what's in this bill for them and for 
their families, but there's also something important in this bill for 
us as a people: a system worthy of the values we profess and the 
principles we hold dear. We will vote for a healthier America. We will 
vote to give our fellow citizens a greater sense of security. We will 
vote to make Medicare stronger for our seniors. We will vote for a 
healthier economy, for affordable coverage for individuals and small 
business. We will vote to begin containing costs, which will otherwise 
be unsustainable for our children and for our grandchildren.
  We will, in sum, my colleagues, on this historic day, vote for a more 
perfect Union of which our Founders dreamed.
  Mr. WAXMAN. Mr. Speaker, I reserve the balance of my time.
  Mr. BARTON of Texas. Mr. Speaker, I yield myself 2 minutes.
  Mr. Speaker, I first want to apologize to my wife, Terry. Back in 
September for my 60th birthday, she gave me a birthday present of a 
weekend in Las Vegas today. I obviously can't be there because I have 
to be here doing my duty for the 6th District of Texas. But like many 
of us, we wear two hats. So to my wife and all the families that had 
things planned this weekend, I do want to apologize.
  I would also point out that my wife works for a public hospital in 
Fort Worth, Texas; and this is something that's very, very dear to her 
heart.
  Mr. Speaker, there are many reasons to oppose the bill before us, 
H.R. 3962. There are numerous policy reasons. It's going to cost over 
$1.2 trillion over 10 years if you include the physician reimbursement 
fix in the separate bill. When fully implemented, it's my opinion that 
two-thirds to three-fourths of every dollar spent on health care in 
America is going to be spent by the Federal Government in some shape, 
form, or fashion. It's going to create, in my opinion, Mr. Speaker, a 
two-tiered health care system: the public system for most of us and 
then a private system for the elites of the country that can afford to 
go outside the public system.
  It's a bad deal for average Americans. The average person today who 
works and has a health care plan through their employer, the average 
plan costs about $10,000 a year. The employee pays $3,500; the employer 
pays $6,500. Since there's an 8 percent payroll tax, on the average of 
$40,000, that would be about $3,200. Most employers, when this plan is 
implemented, can pay the 8 percent tax, which is $3,200, or the $6,500 
premium that they pay for their employees.
  They're going to stop providing health care through the employment 
and they're just going to put them in the public option. The employee 
is going to take that $3,500 that he or she was paying for their 
premium for a $10,000 plan and they're going to find out that when they 
go into the health care exchange, their $3,500 doesn't buy a $10,000 
policy. It buys a $3,500 policy. It's a bad deal.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. BARTON of Texas. Mr. Speaker, I yield myself 1 more minute.
  So there are lots of policy reasons.
  But the real reason, Mr. Speaker, is that I just don't think it's 
right, in the guise of helping Americans, to mandate what they have to 
do. I don't think it's right to mandate that you have to have health 
insurance or you might go to jail. I don't think it's right that you 
mandate an employer to provide health care insurance or they're going 
to pay all these penalties. I don't think it's right that we set up a 
health choice administration that sets what the health care plans have 
to be. I don't think it's right that you say that 70 to 90 percent of 
those premiums of the benefit package that is mandated has to be paid 
by the employer.
  I just don't think mandating to Americans is a good idea, except in a 
few cases. To protect the country in times of war, we have on occasion 
had to mandate our young men, and now our young women, to have to 
serve. We mandate we have to pay our taxes. But we don't have to 
mandate that you need health insurance.

[[Page 27434]]

  Vote ``no'' on the bill and ``yes'' on the Republican substitute.
  Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 3 minutes 
to the majority whip of the House of Representatives, Mr. Clyburn.
  Mr. CLYBURN. I thank Chairman Waxman for yielding me the time.
  Mr. Speaker, today I'm thinking about a woman from South Carolina. A 
few months ago during the August break, I participated in a talk radio 
program on health reform, and a gentleman called in to tell me that his 
health care was great, and he didn't want me or the government to mess 
with it.

                              {time}  1415

  I explained to him that our plan was about choice, bringing down 
costs, and providing quality care.
  But the next caller got right to the heart of the matter. She said, 
Of course he likes his health insurance; it is probably because he has 
never tried to use it. She explained that she had recently been 
diagnosed with cancer and thought she liked her coverage until she 
tried to use it. She said that when she began to get treatment she was 
dropped from her insurance coverage.
  Mr. Speaker, that is why we are here today, to respond to that caller 
and others who have asked, What's in this plan for me?
  When this bill is signed into law, 15 reforms will immediately occur. 
Among them are: beginning to close the doughnut hole by increasing 
Medicare part D coverage by $500; increased funding for community 
health centers, doubling the number of patients seen over 5 years; 
extending coverage for young people to stay on their parents' insurance 
plans up to their 27th birthday; access for the uninsured with 
preexisting conditions to a temporary insurance plan that we are 
calling a high-risk pool; from the date of enactment, and until the 
exchange is available, insurers will be prohibited from dropping your 
coverage if you get sick; from the date of enactment, COBRA health 
insurance coverage will be extended until the exchange is available and 
displaced workers can have affordable coverage; and from the date of 
enactment, we will hinder price-gouging with sunshine requirements on 
insurance companies to disclose insurance rate increases.
  Now, after 2013, when the mandate for coverage and exchange are in 
place, you will see three additional protections: no more copays for 
routine checkups and preventive care; no lifetime or yearly caps on 
what insurance companies will cover; there will be yearly caps on your 
out-of-pocket expenses; and, as has been said so often, there will be 
an end to discrimination because of preexisting conditions like 
diabetes, heart disease or cancer.
  Mr. Speaker, these are just 11 reasons to support this bill. My 
colleagues will share with you many others.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to a member of the 
committee, the gentleman from Illinois (Mr. Shimkus).
  Mr. SHIMKUS. Mr. Speaker, I think it spoke volumes that my friend, 
John Dingell, chaired the rule. John Dingell has always been a single-
payer advocate. That speaks volumes to what the real intent of this 
bill is.
  The goal of this legislation has been clear: to pass a public option 
that will serve as a gateway to a single-payer, government-controlled 
system. Don't trust me; ask my friend, Jan Schakowsky, or ask Chairman 
Barney Frank. Or believe President Obama who said, ``I happen to be a 
proponent of a single-payer health care program. But I don't think 
we're going to be able to eliminate employer coverage immediately.''
  Make no mistake, this bill will achieve the single-payer goal. And 
along with it, it will raise premiums, increase taxes, cuts billions of 
dollars from Medicare, and cost millions of working Americans their 
job. And at the end, a single-payer system will force every American 
into a one-size-fits-all system that rations care. A government that 
rations care is anti-life.
  Mr. WAXMAN. Mr. Speaker, at this time I am very pleased to recognize 
and to yield 1 minute to the gentlewoman from Connecticut (Ms. 
DeLauro).
  Ms. DeLAURO. Mr. Speaker, I rise at this historic moment in support 
of the Affordable Health Care for America Act. None of us will again 
have such an opportunity in our time serving in the United States 
Congress to do something so enduring and fulfilling, to make sure that 
every American shall have access to quality, affordable health 
insurance.
  For more than a century, the special interests have won this moment. 
Presidents Theodore and Franklin Roosevelt, Truman, Kennedy, Nixon, and 
Clinton have spoken of our country's aspiration, but only now have we 
come so far.
  When the Democrats and the Congress passed Medicare, we lifted 
seniors out of poverty forever, and now we get to say to working 
Americans, You can no longer be broken by a health insurance system 
that drops you when you are sick or lose a job.
  It says to women, You will no longer be denied coverage on account of 
a C-section or domestic violence. No longer will maternity or 
preventive care be ignored.
  I urge my colleagues to vote for history and for America today. This 
is why we are here.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will remind all persons in the 
gallery that they are here as guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. BARTON of Texas. Mr. Speaker, I would like to yield 1 minute to 
the gentlewoman from California (Mrs. Bono Mack), a member of the 
committee.
  Mrs. BONO MACK. Mr. Speaker, I rise today to express my strong 
opposition to this bill. It is a bill that flies in the face of the 
Hippocratic oath which both my father and grandfather took as young 
doctors, which says, ``Do no harm.''
  In fact, this bill does a tremendous amount of harm and would inflict 
an enormous burden on current and future generations of Americans. It 
would raise insurance premiums, raise taxes, and create huge new 
government bureaucracies to stand squarely between patients and 
doctors.
  This bill does not offer real health care reform. Rather than reduce 
costs and make health care more affordable and accessible, this bill 
will increase costs to consumers and put the government in charge of 
deciding what treatment and care Americans are entitled to.
  Millions of Americans have resoundingly rejected this shell game 
masquerading as reform. The very least we can do is listen to the 
American people and reject this flawed bill.
  Mr. WAXMAN. Mr. Speaker, I am pleased now to yield 2 minutes to the 
gentleman from Connecticut (Mr. Larson), the chairman of the Democratic 
Caucus.
  Mr. LARSON of Connecticut. Mr. Speaker, I thank Mr. Waxman and Mr. 
Rangel and Mr. Miller for their help.
  The growth of this great Nation cannot be achieved without caring for 
the health of all of its citizens. Thirty-six million Americans await 
our action on the House floor today. Thirty-six million Americans 
watched as the fearmongers stood on the steps of the Capitol this week 
telling them to be afraid.
  The same fear was spread during the debate on Social Security and 
Medicare. Today, we will put a stop to the fear and address the real 
threat, the real danger the American people face. The woman next to you 
on the train spreading the flu because she couldn't afford to see a 
doctor. The little boy in the sandbox with your child whose parents 
couldn't afford the vaccinations. And if we have learned anything from 
the H1N1 epidemic, the billions of dollars these public health 
emergencies cost all of us, and that disease has no boundaries or 
borders; it affects all of us.
  On this historic day, this Congress will pass what will improve both 
the fiscal and physical health of the entire Nation by improving health 
care for all of our citizens. It is a statement of our

[[Page 27435]]

values. It is testimony to how we care for our fellow citizens. It is 
at the very core of all that America stands for and why we came here to 
serve. Thirty-six million Americans deserve nothing less.
  Mr. BARTON of Texas. Mr. Speaker, I yield 2 minutes to the gentleman 
from Georgia (Mr. Deal), a subcommittee ranking member.
  Mr. DEAL of Georgia. Mr. Speaker, I rise in opposition to this bill, 
and I express three major concerns.
  First of all, I raise a question. The question is: what authority in 
the United States Constitution gives this Congress the right to mandate 
that every citizen must purchase a health insurance policy, and upon 
failing to do so, shall be fined and possibly imprisoned? I think the 
answer to that question is, there is no such congressional authority.
  Secondly, make no mistake about it, illegal aliens will receive 
government-funded health care under this because all they are required 
to show is a Social Security number and a name. There is no way to 
prevent the same Social Security number from being used by numerous 
individuals, and there is no requirement that a picture ID be produced 
in order to prove that the person is in fact the name that appears on 
the Social Security card. If you think identity theft is a problem now, 
just wait until this bill passes.
  Thirdly, this bill requires States to increase their Medicaid rolls 
to 150 percent of the Federal poverty level. In an ever-increasing 
fashion, States will have to absorb the cost of this burden. I offered 
an amendment which would have allowed States to opt out from under this 
mandate, but it has been rejected. In States like mine, where we have 
to balance our budget, right now schoolteachers and law enforcement 
officers are having to take unfunded furlough days. If this bill 
passes, it will get even worse. We should not be passing a bill that 
takes days and money out of the paychecks of teachers and law 
enforcement officers to pay for this piece of legislation.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will remind all persons in the 
gallery that they are here as guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 2 minutes 
to the gentleman from the State of Maryland, Mr. Chris Van Hollen.
  Mr. VAN HOLLEN. Mr. Speaker, today our Nation stands at an historic 
crossroads. We can choose the road that dead-ends in the status quo 
where the health industry will continue to call the shots and ration 
our health care or we can pass this bill and take the path that will 
provide every American citizen access to quality, affordable health 
care.
  What we do in this bill is preserve what is best and fix what is 
broken. We currently face unsustainable skyrocketing health care costs 
that are breaking our family's budget, forcing businesses to drop 
health insurance, and will eventually bankrupt our Nation. We saw 
health insurance premiums more than double between 2000 and 2008; and 
during that period of time, health insurance profits soared by 500 
percent. How did they do it? Essentially by saying ``no'' to people who 
had preexisting conditions and using the fine print in insurance 
policies to deny people promised benefits when they needed help the 
most.
  This bill will end those abuses. It ends the antitrust exemption that 
shielded the health insurance industry from price-fixing. It 
establishes a health insurance exchange like a shopping supermarket for 
health policies that provides more choice, including a public option.
  Mr. Speaker, that's why the Consumers Union and Consumer Reports 
support this legislation. That's why the AARP, the largest organization 
protecting the rights of seniors, has endorsed this. And that's why the 
doctors of America have endorsed this.

                              {time}  1430

  I understand why the insurance industry opposes this bill, but our 
job is not to protect the special interests of the insurance industry; 
our job is to do what's right by the American people.
  Let's move this country forward. Let's vote ``yes'' for America.
  Mr. BARTON of Texas. Mr. Speaker, I would like to yield 1 minute to 
another member of the committee, Congresswoman Marsha Blackburn of 
Nashville, Tennessee.
  Mrs. BLACKBURN. Mr. Speaker, I find it so interesting that some are 
so excited about voting for this bill. Quite frankly, I find it to be a 
very sad day that this body would take a step moving toward a single-
payer system in health care.
  We have all heard the horror stories of what happens in Europe and in 
Canada as women seek to get care for breast cancer and die before that 
care can be found, because care delayed is care denied. We've heard 
about heart surgeries that never came to pass because they were waiting 
in the queue. We have talked to mothers who sought desperately to have 
children treated for chronic illnesses and could not get that help. We 
have heard about our seniors, and we know what this bill will do to 
Medicare, making one-half trillion dollars worth of cuts. We have 
talked to mothers who have said, My goodness, you cannot even get H1N1 
vaccine out there and you think you're going to handle the health care 
for my children?
  And today, recorded in the Wall Street Journal, Betsy McCaughey, 
former Lieutenant Governor of New York, cites some of the provisions 
and what it will do to the seniors in this Nation as it cuts into their 
access.
  This is not the action we should take.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The time of the gentlewoman has expired.
  The Chair would ask all Members to adhere to the time limits and to 
heed the gavel.
  Mr. WAXMAN. Mr. Speaker, I yield myself 3 minutes.
  Today, we have a historic opportunity. Sixty-five years after 
Franklin Roosevelt and Social Security and 35 years after Medicare, we 
have an opportunity, under the leadership of President Obama and 
Speaker Pelosi, to reform our health care system and at last provide 
coverage to all Americans.
  We know that health insurance today is failing our families and our 
economy. If we do nothing, the system will go bankrupt, premiums will 
keep skyrocketing, benefits will be slashed, what you get will cost 
more, and the deficit will increase by billions of dollars.
  Today, Americans with health insurance know that they are one serious 
illness away from debt and bankruptcy, and millions of Americans have 
no insurance at all. With this legislation, we can fix these problems.
  First and foremost, this bill provides health insurance security for 
all Americans. If you have health insurance today, you can keep it; you 
keep your doctor and your other health providers. But if you lose your 
job, you will not lose your health insurance. If you have a preexisting 
medical condition, you cannot be denied health insurance. If you have a 
serious illness, we remove the cap insurance companies have imposed on 
paying for treatments over your lifetime. Effective immediately, it 
will be illegal for insurance companies to put lifetime caps on your 
coverage. And children all the way up to age 27 can continue on their 
parents' policies.
  Our bill has historic reforms. It expands coverage and reduces costs. 
It trains doctors and supports community health centers. It provides a 
public health insurance option that will give Americans more choice and 
competition.
  Our legislation strengthens Medicare. We will eliminate copayments 
for preventive services. We close and then eliminate the doughnut hole 
that makes prescription drugs unaffordable for so many of our seniors.
  And this legislation is affordable. The only thing not affordable is 
to do nothing. The legislation is fully paid for. It will not add to 
the deficit over the next two decades.

[[Page 27436]]

  Today, we have the chance of a lifetime to do something great and 
momentous for the American people. By passing this bill, we can reform 
health insurance in America and provide all Americans with the security 
of knowing that when they get sick, care will be available and 
affordable.
  I urge all my colleagues to support this bill.
  Mr. Speaker, I reserve the balance of my time.
  Mr. BARTON of Texas. Mr. Speaker, I yield for a unanimous consent 
request to the former chairman of the Appropriations Committee, Mr. 
Bill Young of Florida.
  Mr. YOUNG of Florida. Mr. Speaker, I rise in opposition to the bill.
  Mr. Speaker, this bill, H.R. 3962, does not represent good public 
policy. I rise to express my concerns about H.R. 3962, the Affordable 
Health Care for America Act.
  This legislation is misnamed, as even the nonpartisan Congressional 
Budget Office says it will not be affordable for the American people 
and our nation as a whole.
  The Congressional Budget Office says this legislation will cost 
$1.055 trillion over the next 10 years, raising taxes on American 
taxpayers and businesses by $729.5 billion. Of great concern to me, and 
the 138,647 Medicare beneficiaries I represent, is that it will also 
cut Medicare payments by $500 billion. There is no possible way you can 
cut such a significant amount of funding out of a program that is so 
vital to senior citizens without compromising the availability or 
quality of their care and without disrupting the relationship they have 
with their current doctors and medical providers.
  Within the Medicare program, H.R. 3962 also cuts the reimbursement 
rate for seniors enrolled in Medicare Advantage programs. In the 10th 
Congressional District of Florida which I represent, more than one-
third of the Medicare beneficiaries, or 47,729 seniors, are currently 
enrolled in Medicare Advantage plans. The Chief Actuary of the Centers 
for Medicare and Medicaid Services estimates that if enacted, the 
legislation we consider today would cut enrollment in Medicare 
Advantage by 64 percent over 4 years. This means that more than 30,500 
of the seniors I represent will lose or have to give up the health care 
coverage they currently have and like. This violates the number one 
promise made by the sponsors of this legislation, who say that if you 
like your current health care coverage, you can keep it.
  The Congressional Budget Office also notes that changes in this 
legislation to the Medicare Part D program will, in the end, drive up 
Part D premiums by as much as 20 percent. These are additional premiums 
that seniors living on fixed incomes will have to pay to keep their 
prescription drug coverage.
  Finally, with regard to Medicare, this legislation does nothing to 
correct a 21 percent cut in physician reimbursement rates that is 
scheduled to take effect January 1st for doctors who provide care to 
our seniors. Having met with doctors I represent throughout the past 
year, I know that one of their major concerns about health care reform 
is that they will be asked to take larger and larger cuts in Medicare 
reimbursement rates. These cuts, they say, will make it more and more 
difficult for them to care for Medicare patients. In the end, many 
seniors could be forced to find new doctors.
  In addition to the impact this legislation would have on senior 
citizens, I am concerned about the economic impact this legislation 
will have on those seniors, their children, their grandchildren, and 
their great grandchildren. H.R. 3962 creates a brand new federal 
entitlement program at a time when our nation is struggling to sustain 
those entitlement programs already on the books. While the 
Congressional Budget Office says that under a best case scenario the 
$500 billion in Medicare cuts and $729.5 billion in tax increases will 
pay for this legislation over its first 10 years if there are no 
unexpected costs, it is doubtful that this will keep the program from 
running up federal deficits after that and leaves no margin for error.
  In fact, despite one of the goals of this legislation to make health 
insurance more available and affordable for uninsured Americans, we 
simply move an estimated 18 million people into the government Medicaid 
program. This is more than half of the 34 million uninsured Americans 
who the Chief Actuary of the Centers for Medicare and Medicaid Services 
says will receive coverage under this legislation.
  Of the 13 million uninsured Americans who will receive coverage under 
the Health Insurance Exchange program created in this legislation, the 
Chief Actuary estimates that 40 percent, or 5.2 million, will take 
advantage of the government subsidized public option created by H.R. 
3962.
  The creation of a government subsidized public option is another 
major concern of the large majority of my constituents who have called 
and written me in opposition to this legislation. We are concerned 
about the insertion of the federal government into the precious 
patient-doctor relationship. At last count, this 1,990 page bill 
creates more than 100 new boards, bureaucracies, commissions and 
programs. Among those created by the bill is the ``Health Benefits 
Advisory Committee,'' that would be chaired by the U.S. Surgeon 
General, to make recommendations on cost and coverage issues.
  This 27-member government committee of unelected administrators will 
be in charge of advising other bureaucrats, who will then decide what 
procedures American citizens are allowed to have and what doctors you 
are allowed to see under your healthcare plan. This places another 
layer of bureaucracy between you and your doctor.
  This committee is in addition to another newly created federal 
organization called the ``Health Choices Administration,'' which will 
be governed by a new Commissioner who will distribute billions of 
dollars of taxpayer-funded subsidies. Additionally, the Commissioner 
will have complete control over all insurance plans offered through the 
newly created Health Insurance Exchange.
  Perhaps the toughest of the mandates handed down by the federal 
government under this legislation is that businesses must provide 
health care for their employees or pay an 8 percent payroll tax and 
that individuals must purchase health insurance or pay a 2.5 percent 
tax on their adjusted gross income. This is not the federal government 
providing incentives to individuals or employers. This is the federal 
government imposing its will on individuals and businesses, and 
penalizing those who do not comply.
  This legislation further penalizes small businesses by imposing a 5.4 
percent surtax on individuals earning more than $500,000. Half of these 
so-called ``high earners'' are small business owners. Just imagine how 
small business owners all across our nation will react to this $544 
billion in new federal taxes they will pay over the next 10 years. With 
the unemployment rate nationally at 10.2 percent and 11.4 percent in 
Florida, Congress should not be making it harder for business owners to 
create new jobs.
  Finally, at a time when we are trying to lower health care costs, 
this legislation imposes a new 2.5 percent excise tax on the cost of 
wheelchairs, portable oxygen systems, diabetes testing equipment, and a 
whole range of other medical devices. This tax will be paid by our 
constituents who have no choice but to purchase this medical equipment 
and who may already be stretched thin by other medical costs.
  Mr. Speaker, I have discussed here some of my concerns about 
provisions in this bill; however there are glaring omissions to this 
legislation as well. The most significant provision that has been left 
out is medical liability reform. This is a top issue for doctors, 
hospitals and all medical providers, as it is one of the major drivers 
increasing the cost of health care. Tort reform would help reduce the 
filing of unwarranted lawsuits, decrease the number of duplicative 
tests that are a part of defensive medicine, and lower the cost of 
medical malpractice insurance rates, which would translate in lower 
medical costs.
  Tort reform is one of the many areas that we can and should be able 
to agree upon to increase the availability and decrease the cost of 
health care. There are others I support, some in this bill, including 
requiring coverage for individuals with pre-existing conditions, 
preventing insurance companies from cancelling the policies of 
individuals when they become sick, providing for the availability of 
health insurance across state lines, ensuring that employees can retain 
access to health insurance when they change or lose their jobs, 
creating health insurance pools that small business owners and self-
employed individuals can join to provide lower cost health insurance 
for their employees and themselves, and closing the so-called doughnut 
hole in the Medicare Part D prescription drug program.
  Mr. Speaker, there is no doubt that our nation can and should do 
better to provide quality and affordable health care for the American 
people. Throughout my service in Congress, I have done all I could to 
expand health care opportunities nationally and throughout the 10th 
Congressional District, which I represent.
  By establishing the National Marrow Donor Program in 1986, I sought 
to provide life-saving medical options to terminally ill patients 
suffering from leukemia and more than 60 otherwise fatal blood 
disorders. Today the national registry has more than 7 million 
volunteers available to donate the life-saving bone marrow.

[[Page 27437]]

  During the time that I worked to establish the national registry and 
as we began to find matched marrow donors for patients, I met with 
family after family who needed help convincing health insurance 
companies to cover the marrow transplant procedure. From this 
experience, I witnessed first-hand the tragedy of families losing their 
health insurance coverage at their time of greatest need and of being 
denied coverage for a life-saving procedure.
  In a similar manner, I have identified other national and local 
health care needs and have done something to solve the problems that 
include increasing the vaccination rates for our nation's children; 
ensuring the availability of specialized services, facilities and 
equipment at our nation's hospital emergency rooms to meet the needs of 
children; expanding the funding for graduate medical education programs 
to increase the number of doctors who receive the next step of their 
training; increasing the Inspector General force at federal agencies to 
uncover waste, fraud and abuse which threaten the safety of seniors and 
veterans, and divert limited federal health care resources; improving 
the quality of health care through our investment in biomedical 
research by doubling the budget for the National Institutes of Health 
during my 6 years as Chairman of the Appropriations Committee; 
expanding other research opportunities through the Department of 
Defense in the areas of breast cancer, prostate cancer, Parkinson's 
Disease, ALS, multiple sclerosis and diabetes; and expanding the number 
of community health centers throughout Florida and Pinellas County.
  Mr. Speaker, I take a back seat to no one when it comes to my work to 
improve and expand the quality and availability of health care for the 
American people and the people I represent. I supported the creation 
and expansion of the State Children's Insurance Program, which 
increases access to health care for our nation's youth, and likewise 
the Family and Medical Leave Act, allowing employees to take time off 
from work to care for a sick and recovering family member.
  However, I cannot support legislation that would threaten the 
sanctity of the patient-doctor relationship, that would establish new 
federal bureaucracies that would insert themselves into the health care 
programs of individuals and employers, that creates a new and 
financially unsustainable federal entitlement program, that threatens 
the availability of health care for our nation's seniors, that raises 
taxes substantially and threatens the viability of many small 
businesses at a time when we are trying to get our nation's economy 
back on track, and that ultimately will not make health care insurance 
more affordable for the American people.
  We have all heard from the American people we represent over the past 
few months that this legislation has been under consideration. We have 
heard that they are closely following its progress. We have heard that 
they have many concerns about this legislation before us. And we have 
heard that they want us to work together in a bipartisan manner to 
bring down the cost and expand the availability of health care 
coverage.
  Today, we have a historic opportunity to tell the American people we 
hear their voices. We can commit to them that, on this issue which will 
affect every single household and business in our nation, we will go 
back to our respective committees and work together--as Republicans and 
Democrats; conservatives, moderates and liberals; Blue Dogs and 
Progressives--to come up with a solution that the American people can 
support and, most importantly, have confidence knowing it will do the 
job without bankrupting our nation, jeopardizing our economic recovery 
and violating the free market principles upon which our nation was 
founded.
  Mr. BARTON of Texas. Mr. Speaker, I yield a clock 3 minutes to the 
minority leader, Mr. Boehner. This is not his leadership imperial 
minute. It is the clock 3 minutes.
  Mr. BOEHNER. Let me thank my colleague for yielding.
  It will be no surprise to any of you that I rise in opposition to 
this bill.
  One of the issues in this bill that is of concern to Members on both 
sides of the aisle has to do with the sanctity of life. The Rules 
Committee made in order an amendment by our colleague from Michigan 
(Mr. Stupak) that would continue existing law that no Federal funds 
will be used for abortion.
  While I am grateful that we're going to have this vote in the House, 
I want to ask the chairman of the Energy and Commerce Committee, Mr. 
Waxman, if the House does vote, in fact, for Mr. Stupak's amendment, if 
the gentleman will guarantee me that when this bill comes back from 
conference, that that language will remain in the bill.
  Mr. WAXMAN. If the gentleman would yield.
  Mr. BOEHNER. I would be happy to yield.
  Mr. WAXMAN. As the gentleman well knows, the decision is not up to 
one person; it will be up to the conferees. The conferees will have to 
be meeting with the Senate conferees and going over a number of 
positions.
  If this amendment is adopted by the House, it will be the House 
position as we go into conference. We will have to discuss it further, 
and then we will see what will be the result. But no guarantee can be 
made by me or any other Member at this time.
  There will be an opportunity, as you know, to instruct the conferees, 
which reinforces, of course, a particular part of the House bill.
  Mr. BOEHNER. Reclaiming my time, the reason that I rise at this point 
in the debate is that, while we are grateful to have this amendment and 
this chance to vote to make sure that taxpayer funding is not used for 
abortion--which has been the policy of the land for the last 30 years--
as the gentleman pointed out, there is no guarantee that at the end of 
the day this language will be in the bill.
  Now, I've been a chairman of a committee. I understand that there are 
no guarantees, but that's the whole point here. The only reason this 
amendment is allowed to be offered is in order to secure enough votes 
to try to move this bill through the floor today. I have my doubts 
about whether this language, if it passes, has any chance of ever being 
in the final version of this bill.
  Mr. WAXMAN. Mr. Speaker, at this time, I am honored to yield 2 
minutes to the gentleman from New Jersey (Mr. Pallone), the chairman of 
the Health Subcommittee of the Energy and Commerce Committee.
  Mr. PALLONE. Mr. Speaker, I want to thank my chairman, Mr. Waxman, 
for all his hard work on this bill.
  For far too long, our Nation has endured a health care system that is 
chaotic, costly, and crippling American families. In casting our votes 
today, each of us must make a simple choice: Do we want to maintain the 
broken system we currently have or do we want to make it better?
  And you should ask yourself, first, are you in favor of allowing 
health care premiums for American families to continue to spiral out of 
control, forcing them to delay care or drop coverage altogether, or are 
you in favor of providing every American with access to affordable and 
quality health insurance?
  Second, are you in favor of more American families falling into 
bankruptcy under the weight of medical bills, or are you in favor of 
providing every American with the security of knowing that they won't 
go broke if they get sick?
  Third, are you in favor of more American businesses delaying 
investments, closing their doors or laying off workers because of 
increasing health care costs, or are you in favor of making it more 
affordable for those businesses to provide health care coverage for 
their workers?
  And finally, are you in favor of allowing health insurance companies 
to be able to discriminate against people because they are sick, women, 
or older, or are you in favor of putting an end to this explicit and 
immoral form of discrimination that insurance companies get away with 
today?
  Mr. Speaker, there are many reasons to vote for this bill, but there 
is really only one reason to vote against it, and that is to maintain 
the broken health care system we currently have.
  If you want to change the system, vote ``yes''; vote for affordable 
and quality health care for every American.
  Mr. BARTON of Texas. I yield 2 minutes to a member of the Republican 
leadership, Mr. McCarthy of California.
  Mr. McCARTHY of California. I thank my friend for yielding.
  Mr. Speaker, this is my second term. Since being elected by the 
people of California's 22nd District, I am reminded about how much 
things have changed.

[[Page 27438]]

  Three years ago on this date, unemployment was 4.5 percent. Today, 
the unemployment rate has more than doubled to a 26-year high of 10.2. 
Three years ago on this date, the stock market was over 12,000. Today, 
the stock market has dropped by 2,000 points. Three years ago on this 
date the current House majority promised to drain the swamp. Today, the 
swamp in Washington isn't drained; it's overflowing. And 3 years ago on 
this date, November 7, 2006, the Democratic Party was victorious in 
winning control of this House.
  Today, we are here on the floor to vote on a $1 trillion government 
takeover that can replace the health insurance that millions of 
Americans have. This is a defining vote for this Congress. We can 
reject tax increases on small business at a time when 2.8 million jobs 
have been lost since the stimulus was signed into law and say yes to 
helping small businesses access more affordable health insurance for 
their employees. We can reject the government takeover of our health 
care that will increase health insurance costs and say yes to saving 
American families up to $5,000 off their current health care premiums.
  I know that over the last 3 years there have been many 
disappointments, when the voices of Americans have been overruled by 
government bailouts and now a government takeover of health care, but I 
urge my colleagues to reject the politics of the past and fight for a 
better direction for our country, for our children, and for our 
grandchildren.
  I urge a ``no'' vote on H.R. 3962 and a ``yes'' vote for the 
Republican bill.
  Mr. WAXMAN. Mr. Speaker, this bill reflects the input and the 
inspiration of two Kennedys in the Congress of the United States, 
certainly Senator Ted Kennedy, but also Patrick Kennedy, who has been 
such a leader in the areas of mental health and addiction.
  I yield to the gentleman from Rhode Island for a unanimous consent 
request.
  Mr. KENNEDY. I rise in support of mental health benefits in this bill 
to support suicide, addiction, and depression coverage in this 
legislation for whole health coverage.


                             General Leave

  Mr. WAXMAN. Mr. Speaker, I ask unanimous consent that Members have 5 
legislative days in which to revise and extend their remarks on H.R. 
3962 and include extraneous material in the Record.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.
  Mr. WAXMAN. Mr. Speaker, at this point, I am greatly honored to yield 
3 minutes to the chairman of the Ways and Means Committee, one of the 
crafters of this bill and one of the great leaders in health care as 
well as other policy areas, the gentleman from New York (Mr. Rangel).
  Mr. RANGEL. We have an expression in my community, ``God is good,'' 
and basically it means that it gives us all an opportunity in our lives 
to do some of the things that we had hoped and dreamed would be 
possible. Since God has been good to our country and to this Congress, 
it means that we have a responsibility to extend our power to make 
certain that people have access to health care.
  It's really surprising that the other side would believe that, as a 
party, their answer to this crisis that we face as a Nation in 
providing health care to so many millions of people that don't have it, 
that their answer is ``no'' and their vote will reflect ``no.'' But a 
short visit to history would see that every time we're talking about 
compassion--Social Security, Medicaid, and Medicare--their answer is 
going to be ``no.''
  I want to thank our President for recognizing that even though we 
have to carry this load alone, it is an honor to be working under the 
leadership of Speaker Nancy Pelosi, our chairmen, Chairman Waxman and 
Chairman Miller, and all of the wonderful people that have worked 
together under the caucus chair of Mr. Larson so that we all would 
understand that we only have this one chance to get it right; Mr. 
Clyburn, who brought our votes together so that we are able to be here 
on this Saturday to pass this. But to me, most of all, it would be the 
hardworking members of my committee, men and women who worked day and 
night to make certain that we got out our initial bill and we also 
found a way to pay for it. And not only to make certain that this great 
Nation of ours would not have a deficit but, indeed, would decrease the 
deficit of this country by $100 billion over 10 years. And the staff, 
of course, of the Ways and Means Committee that serviced not just our 
committee, but all of the committees in the House and every Member who 
needed to know just how can we get this thing right and to do the right 
thing.
  How proud we are that nobody is going to be denied health care 
because they had a preexisting condition before that. How proud we are 
that we don't have to select our jobs based on the health insurance 
that we have. And how proud we are that people who lose their jobs will 
not be losing their health coverage.
  It is a small thing for some people like Members of Congress that 
already have their insurance, but for those of us that have the 
compassion to understand what it's like not to be able to take care of 
your family or your dear friends, not to be able to have health 
insurance, and for a Nation to be able to say that we are competing 
with industrial countries all over the world and they provide education 
and health care for their children, and this great country of ours, 
with all of the wealth, have to shamefully say that we can't afford to 
take care of our own people.

                              {time}  1445

  So, to those who don't understand what we're doing, this is going to 
be a historic day for you as well. Unfortunately, it won't be like it 
would be for us, because we can now have our names under Roosevelt's 
and under Obama's and under the right thing.
  God is certainly good.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the 
distinguished ranking member of the Science Committee and a member of 
the Energy and Commerce Committee, the gentleman from Rockwall, Texas, 
Congressman Ralph Hall.
  Mr. HALL of Texas. Mr. Speaker, I rise today to urge, of course, a 
``no'' vote on the Democratic health care proposal.
  I have five grandchildren, and already they will spend their entire 
lives paying the debts that we are accumulating. They will be in their 
late sixties before they are even paid. This bill is a generation 
killer, and the targets are your grandchildren and mine. My Fourth 
District of Texas is 100-1 against this bill, and I believe it's a good 
composite of other districts around the country.
  I urge you all to please listen and to vote with your constituents, 
and I say to Members on both sides of this aisle: remember who sent you 
here, and vote their wishes. The American people have memories that 
will survive the actions of today's vote. They will not forget. I ask 
you to vote ``no.''
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California, Anna Eshoo.
  Ms. ESHOO. Mr. Speaker, I come to the floor today to cast one of the 
most important votes of my congressional career, a vote for the 
Affordable Health Care for America Act. This effort is historic, almost 
a century in the making.
  For many of us, this long battle has had a singular, courageous 
champion who fought like a lion for the sick, the elderly, the left 
behind, and the left out, Senator Edward Kennedy, and this bill is a 
fitting memorial to him.
  Most uninsured Americans want to purchase health insurance, but they 
simply can't afford it. They are priced out. The middle class is priced 
out. Millions more live under the crushing weight of medical bills that 
bankrupt households or that shutter small businesses. This bill 
provides access to affordable health care for every American.
  The abhorrent insurance practices of dropping sick patients to avoid 
paying expensive medical bills and discriminating against those with 
preexisting

[[Page 27439]]

conditions will end with this legislation.
  Very importantly, seniors, your Medicare will be strengthened; and it 
will provide you with better care.
  I am proud to be part of making history. I think it is a privilege to 
do so. I urge all of my colleagues to vote for this legislation.
  The SPEAKER pro tempore. The Chair will note that the gentleman from 
Texas has 28 minutes remaining, and the gentleman from California has 
22\1/2\ minutes remaining.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to a distinguished 
member of the Energy and Commerce Committee, one of our ranking members 
of the subcommittee, the gentleman from Michigan (Mr. Upton).
  Mr. UPTON. Mr. Speaker, I rise against this bill. I don't know if you 
saw the headline today in The Wall Street Journal: ``Grim Milestone as 
Jobless Rate Tops 10 percent.'' The New York Times: ``Jobless rate hits 
10.2 percent with more unemployed. Official figure is highest since 
1980. Broader measure stands at 17.5 percent.''
  Mr. Speaker, I am from Michigan where our unemployment rate exceeds 
15 percent. People want to work and pay taxes. They don't want to be 
laid off and receive benefits.
  This 1,990-page bill is almost 20 pounds. Does anyone actually 
believe that spending another $1 trillion is going to reduce our 
unemployment? We add employer mandates. The Joint Committee on Taxation 
says that one-third of the $460 billion in taxes is going to be paid 
for by small businesses. How does that decrease our unemployment? It 
doesn't.
  In closing, Mr. Speaker, let me say this: one of our colleagues today 
is quoted as saying: Health care costs are rising faster than wages and 
inflation, and this bill does not change that trend.
  That was a Democrat and not a Republican who said it.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a member of our 
committee, the gentleman from New York, Eliot Engel.
  Mr. ENGEL. Mr. Speaker, I rise in strong support of the Affordable 
Health Care for Americans Act.
  As a senior New Yorker on the Energy and Commerce Committee and on 
the Health Subcommittee, I am proud of the role I played in helping to 
make this bill a reality.
  On this historic day, our Congress honors our country; it honors our 
citizens; and it honors a moral imperative to provide all Americans 
with comprehensive, affordable access to quality health care.
  This is the reason why so many of us sought public office, and it is 
the reason why our constituents sent us to Congress, to right the 
wrongs of our broken health care system and to steer our country back 
in the right direction.
  Never again will families worry late into the night over whether 
their preexisting medical conditions will prevent their loved ones from 
getting access to the health care coverage they so desperately need. 
Never again will insurance companies be allowed to drop coverage for 
those who have paid their premiums diligently only to have their 
policies canceled when they get sick and need it the most. Never again 
will families have to worry that, if they lose their jobs, they will 
also lose their health care coverage.
  Don't believe the scare tactics you are hearing from the other side. 
This bill is good for seniors, good for young adults, and good for all 
Americans. I urge my colleagues to support the bill.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the 
distinguished former mayor of Fort Worth, Texas, the Honorable Kay 
Granger.
  Ms. GRANGER. Mr. Speaker, unemployment is over 10 percent in this 
Nation. Our debt is nearly $12 trillion. Our deficit is $1.4 trillion.
  Families are sitting at their kitchen tables trying to figure out how 
to pay their bills. Businesses have cut everything they can cut just to 
keep their doors open. Grandparents are taking in their kids and their 
grandkids.
  We are going to vote another $1 trillion so government can take over 
our health care, cost those families more money, throw more mandates on 
our States, add 118 new departments and agencies to this already 
bloated Federal Government, take Medicare Advantage away from our 
seniors, let the health choices commissioner take the place of our 
family doctors, mandate health insurance with jail for not complying 
with or for paying a tax, and ignore the voices of thousands of people 
who came here and who said, Listen to us. Don't pass this bill.
  Mr. Speaker, what are people in this Chamber thinking of?
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a member of our 
committee, the gentleman from Texas, Gene Green.
  Mr. GENE GREEN of Texas. Mr. Speaker, I rise in strong support of 
H.R. 3962, the Affordable Health Care for America Act. This is a 
momentous day like that day in 1935 when Social Security was created 
and also like that day in 1965 when Medicare was passed.
  We are in desperate need of health care reform. Health insurance 
premiums are growing three times as fast as wages; and, last year, more 
than half of Americans postponed medical care or skipped their 
medications because they couldn't afford them.
  The 29th District in Texas, which I represent, has the highest number 
of uninsured individuals in the country as 40 percent of the residents 
are uninsured. If enacted, H.R. 3962 will provide coverage to 96 
percent of all Americans and to 230,000 currently uninsured residents 
in our district. It will also improve the employer-based coverage for 
217,000 residents in our district.
  H.R. 3962 will give individuals the ability to access quality, 
affordable health insurance. They will no longer be denied coverage for 
preexisting conditions, and their coverage will not be capped or 
dropped when they are sick. The bill ensures no more co-pays for 
preventative care, no more yearly caps for what insurance companies 
will cover, and it provides premium subsidies for those who need it.
  This is not government controlled medicine--individuals will be able 
to choose their own insurance plan and their physician.
  This bill ensures individuals will be able to have access to primary 
and preventive care services so they will be able to see a doctor 
before they are sick, and be able to access quality medical services.
  H.R. 3962 will rein in rising health costs for American families and 
small businesses--introducing competition that will drive premiums 
down, capping out-of-pocket spending.
  The time for health reform has come and I urge my colleagues to vote 
in favor of H.R. 3962 not only for my constituents, but for all 
Americans.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to one of the 
distinguished ranking members of the Energy and Commerce Committee, the 
gentleman from Florida (Mr. Cliff Stearns).
  Mr. STEARNS. I thank my colleague.
  Mr. Speaker, I rise against this bill. The Congressional Budget 
Office has said that tort reform will save the Federal Government $54 
billion. Instead, we get a bill today that makes a mockery of tort 
reform.
  The Democrats add a provision that will clearly increase costs for 
health care and that will make it harder to recruit doctors. The new 
language explicitly prevents States who accept these grant funds from 
capping noneconomic damages or attorneys' fees even if it is current 
law.
  Said another way, the Secretary of Health and Human Services can give 
such sums as he deems necessary to any States that do not cap 
attorneys' fees, or said another way, the bill undoes all States' tort 
reform.
  This bill violates States' rights. It undermines their efforts at 
real tort reform. It allows trial lawyers to begin open season on our 
doctors and medical providers.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a very active and 
important member of the Health Subcommittee and of the full Energy and 
Commerce Committee, my colleague from California, Lois Capps.
  Mrs. CAPPS. Mr. Speaker, I am honored to rise in emphatic support of 
H.R. 3962. As we pass this historic legislation today which improves 
health

[[Page 27440]]

care for all Americans, I want to focus on the benefits for women's 
health.
  When this bill becomes law, a woman will no longer be discriminated 
against by an insurance company simply for being a woman. Women will no 
longer be discriminated against by insurance companies for being 
victims of domestic violence. Women will automatically be covered for 
maternity care. Women will not have to pay co-pays for important 
preventative screenings, like mammograms and cervical cancer. Most 
importantly, women who make the bulk of the health care decisions for 
their families will have access to quality, affordable health care for 
their families.
  This is an excellent bill, and I am humbled by the fact that, as a 
Representative of the 23rd Congressional District in California--a 
nurse, a mother and a grandmother--I am privileged to vote today in 
favor of this bill. I urge all of my colleagues to do the same.
  Mr. BARTON of Texas. I yield 1 minute to another of my distinguished 
ranking members on the Energy and Commerce Committee, the gentleman 
from the Bluegrass State of Kentucky (Mr. Whitfield).
  Mr. WHITFIELD. Mr. Speaker, there are many provisions of this 2,000-
page Affordable Health Care for America Act that we can support on this 
side.
  Yet we do not support the establishment of a Federal health care 
board to control health care in America. We do not support establishing 
civil penalties of up to $10,000 a day for violating health 
regulations. We do not support reducing Medicare funding by $500 
billion. We do not support cutting funding for hospitals by $155 
billion and rural hospitals by $6 billion between 2017-2019. We do not 
support increasing taxes on small business owners, particularly at a 
time when we have an unemployment rate of 10.2 percent.
  If we had a surplus, we could support spending billions of dollars 
for the sovereign states of Micronesia, the Marshall Islands and Pulau. 
Since we have a $11 trillion debt, why should we be spending money for 
health care in those countries? We are also increasing by $10 billion 
health care for Puerto Rico, the Virgin Islands, Guam, the Northern 
Mariana Islands, and American Samoa in this bill.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from 
Pennsylvania (Mr. Doyle).

                              {time}  1500

  Mr. DOYLE. Mr. Speaker, my colleagues on the other side of the aisle 
are trying to scare our seniors. They are telling tall tales, saying 
that passing health care reform will destroy Medicare.
  For Americans watching this debate, I want to make this clear: This 
bill will strengthen Medicare. My good friend from Michigan, John 
Dingell, helped write the law that created Medicare, and he authored 
this health care reform bill we will vote on today.
  This bill protects seniors and gives all Americans access to quality, 
affordable health insurance. This bill will start to close the Medicare 
prescription drug doughnut hole and ban insurance companies from 
dropping people for having the audacity to get sick. This bill makes 
sure that preventive services are free to seniors in Medicare and all 
Americans with insurance.
  This bill extends the Medicare's solvency by at least 5 years, it 
pays for itself and it will reduce the national debt. Finally, this 
bill is endorsed by doctors, nurses, patients, the Autism Society of 
America and the AARP.
  Mr. BARTON of Texas. I would like to yield 1 minute to the gentlelady 
who has the privilege of representing Key West, Florida, the Honorable 
Ileana Ros-Lehtinen.
  Ms. ROS-LEHTINEN. Mr. Speaker, I am blessed that even though my 
elderly mother has Alzheimer's, we are able to provide her with high 
quality health care, but I am worried.
  I am worried about the families who, like mine, have an elderly 
parent who needs care and assistance. It's not easy for any family to 
support a loved one through hard times, and there is no doubt that 
these are hard times.
  Unemployment in my area of south Florida is over 11 percent. In the 
midst of this, the Pelosi bill takes away from seniors. Yes, it does. 
The Pelosi bill makes $170 billion in cuts to Medicare Advantage, 
causing 3 million seniors to lose their current coverage. The Pelosi 
bill will increase Medicare prescription drug premiums by over 20 
percent, a rate unaffordable to most seniors.
  When I see my mother, I know that health care reform should not occur 
at the expense of America's seniors. Reject the Pelosi sock-it-to-the-
seniors plan.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from the 
State of Washington, a very important member of the Energy and Commerce 
Committee, Mr. Inslee.
  Mr. INSLEE. Mr. Speaker, I just want to relate one call from a small 
businessman who told me we needed health care reform so that his wife 
can finally start a small business of her own and be freed from the 
insurance industry that stopped her from getting insurance.
  I would like to enter into a colloquy with Mr. Waxman.
  Mr. Chairman, I would like to clarify section 1188, the generic fill 
provision in the bill. This section allows Medicare part D plans to 
waive patient's copays for generic, bioequivalent and biosimilar drugs. 
I believe that absent explicit approval from the patient's doctor, this 
inducement should only apply to those biosimilars that have been rated 
``interchangeable'' by the FDA, meaning that they can be expected to 
produce the same clinical result in any given patient and switching 
medicines poses no greater risk than not switching. With respect to 
biosimilars that have not been rated as interchangeable, is it your 
intent that under this provision patients could not be switched to a 
non-interchangeable biosimilar drug without an explicit request by a 
patient and approval by their doctor?
  Mr. WAXMAN. Congressman Inslee, you are correct. It's our intent that 
the patient would not be switched from a referenced product to a non-
interchangeable biosimilar without approval from the doctor.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. WAXMAN. I yield the gentleman an additional 30 seconds.
  Our intent is also that a patient could not be financially induced by 
their plan to switch to a non-interchangeable biosimilar without the 
consent of their doctor, and I am happy to work with the gentleman to 
clarify the language in conference.
  Mr. INSLEE. Today we should pass this bill.
  Mr. BARTON of Texas. Mr. Speaker, I would like to yield 2 minutes now 
to the leader of the Republican Health Care Task Force and a member of 
our committee, the deputy ranking member, Mr. Roy Blunt.
  Mr. BLUNT. Thank you, Mr. Barton.
  Mr. Speaker, there are so many things that I am for in health care. 
In our Health Care Solutions Group, I am sponsoring a dozen bills. The 
core of those bills we will talk about later when we get to the 
Republican substitute.
  But if those bills cost $1.1 trillion, the bills I am for, I would be 
against those bills. We can't afford this bill. It cuts Medicare $505 
billion. It raises taxes.
  There is no estimate I see of people who have estimated the job 
impact who don't say that it cuts jobs. Instead, it's a 2,000-page 
roadmap to a government takeover of health care.
  We could be here today talking about real reforms, medical liability 
reform, access for everybody regardless of preexisting conditions. We 
think you can do that by expanding a risk pool concept. It costs a 
little money, but it doesn't cost billions and billions and billions of 
dollars.
  If we could find Medicare savings, Mr. Speaker, we should use those 
Medicare savings to save Medicare. Only the government would have made 
a commitment to a program like Medicare, know that program is in huge 
trouble beginning in about 2017, and be here today saying we should 
make savings from that program to fund a new program. If there are 
savings in Medicare, we should be using them to save Medicare, Mr. 
Speaker.

[[Page 27441]]

  I hope we reject this bill. Even if this bill passes today and 
doesn't go further than this, I hope we can work together to do the 
things we really need to do to reform the system.
  Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the 
gentleman from the State of North Carolina, an important member of our 
committee, Mr. Butterfield.
  Mr. BUTTERFIELD. I thank the gentleman for yielding the time.
  Mr. Speaker, later today we will have an opportunity to fix a broken 
health care system. I have listened to both sides of this debate, I 
have read everything available, and I have prayed for guidance.
  We have an obligation, constitutional and moral, to provide for the 
general welfare of every American citizen. Allowing a broken health 
care system to continue to bankrupt families, businesses and hospitals 
and deny coverage to millions is a failure of duty.
  We must act now. Reject the false rhetoric surrounding this debate. 
Reject the false claims about Medicare coverage reductions. The bill 
strengthens Medicare. Reject the false rhetoric about government-run 
health care. The bill provides healthy and needed competition.
  Reject the claim that this legislation will increase the debt. Doing 
nothing will increase the debt by billions. We should not delay any 
longer.
  I urge my colleagues to vote ``yes'' on this legislation.
  Mr. BARTON of Texas. Mr. Speaker, I see that we have changed from the 
Jets and the Giants to the Green Bay Packers in the chair.
  I would like to yield 1 minute to a Ramblin' Wreck from Georgia Tech, 
a member of the Committee on Energy and Commerce, Dr. Gingrey.
  Mr. GINGREY of Georgia. Mr. Speaker, having spent most of my life in 
medicine and healing the sick, I rise in strong opposition to this 
bill. With double-digit unemployment at 10.2 percent, this so-called 
reform, which will destroy an additional 5.5 million jobs, is not what 
the American people want. Yet their opposition and protests have fallen 
on deaf ears as this majority simply does not seem to care.
  One can perhaps see why. Democrats have the White House, 60 votes in 
the Senate and an 81-seat majority in this House. They have all the 
power. They can pass government-run health care without one single 
Republican vote. Mr. Speaker, just because they can does not mean they 
should. Might does not make it right. With $750 billion in tax 
increases, $500 billion cuts in Medicare, Mr. Speaker, if the House 
proceeds down this precarious path, I have no doubt that though the 
American people may forget what was said here, they will never forget 
what was done here and who did it to them.
  Mr. WAXMAN. Mr. Speaker, I yield for the purpose of a colloquy to the 
chairman of the subcommittee, Mr. Pallone, 1 minute.
  Mr. PALLONE. Thank you, Chairman Waxman.
  The bill we are debating today includes the CLASS Act, a bill I 
sponsored, along with Representative Dingell, which would encourage 
individuals to plan ahead for future long-term care needs. But there 
are other things we can do to help increase the availability of home 
and community-based services. The Empowered at Home Act, H.R. 2688, 
which I sponsored with Representative DeGette, helps encourage States 
to improve and increase access to home and community-based services 
under their Medicaid programs.
  While we were not able to include these other provisions from the 
Empowered at Home Act in H.R. 3962, I hope that we can consider their 
inclusion in the final health reform bill that emerges from the 
conference with our Senate colleagues.
  Mr. WAXMAN. I want to thank the gentleman from New Jersey for his 
leadership on the bill before us today and for his tireless efforts on 
behalf of low-income Americans who need long-term care. I support the 
elimination of barriers to the provision of home and community-based 
services under Medicaid, a result that the gentleman's Empowered at 
Home Act would achieve.
  The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has 
expired.
  Mr. WAXMAN. I yield the gentleman an additional 30 seconds.
  I will continue to work with you and other Members to enact 
legislation that gives State Medicaid programs a robust option for 
offering low-income Americans the choice of receiving long-term care 
services in the community rather than in a nursing home.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentlewoman 
from Missouri, who represents the hometown of Rush Limbaugh, Cape 
Girardeau, Missouri, Congresswoman Jo Ann Emerson.
  Mrs. EMERSON. Mr. Speaker, this could have been a great day in the 
House of Representatives, but we have missed an opportunity for 
consensus, to improve access and save money for taxpayers and patients 
alike. Americans pay the highest prices for prescription drugs in the 
world and this bill binds us to that fate.
  For every Member of Congress, there are two and a half pharmaceutical 
lobbyists. In the first half of 2009, drug companies spent $609,000 
every day on lobbying. We have missed an opportunity to tell the drug 
companies that they no longer set the agenda in Congress.
  We have missed an opportunity to put the interests of Americans ahead 
of special interests. We have missed an opportunity to end the pill-
splitting, skipped doses and unfilled prescriptions that plague 
Americans who can't afford the medicine their doctor prescribes.
  This bill shifts those costs from patients to taxpayers, from this 
generation to the next. It trades affordable generics for pricey name-
brand name drugs. It intentionally makes quality care more expensive 
for our Nation, and it is wrong to leave hundreds of billions in 
savings on the table.
  Mr. WAXMAN. Mr. Speaker, I am pleased to yield 1 minute to a very 
important member of our committee, the gentlewoman from the Virgin 
Islands (Mrs. Christensen).
  Mrs. CHRISTENSEN. Thank you, Mr. Chairman.
  Mr. Speaker, as a family physician who practiced for more than 20 
years, a mother, a grandmother and an American, I am proud to stand 
here in support of the Affordable Health Care for America Act. This 
bill is for the many patients I know who put off health care until it 
was too late because they couldn't afford it and the tens of millions 
like them who will now have access to full health care.
  This year and every year past, over 80,000 African Americans died, 
whose deaths were preventable, because they were unable to get health 
care. This bill is for all people of color, those in our rural areas, 
the territories and the poor, because beyond insurance, this bill will 
provide the services some of them never had.
  H.R. 3962 will give young people for whom a health care professional 
is out of the reach the opportunity to help heal their communities. It 
will cover 36 million uninsured people, making insurance secure and 
affordable, strengthen prevention and public health, improve Medicare 
and Medicaid, help poor communities, create an environment that 
supports good health, and finally begin to eliminate health 
disparities.
  Today we have the opportunity to vote for health and a better life 
for everyone in this country and for a better country where life, 
liberty and the pursuit of happiness is truly a right for all.
  Let's make history together. Vote ``yes'' for affordable health care 
for America.
  Mr. BARTON of Texas. Mr. Speaker, I recognize one of my ranking 
subcommittee members, Mr. Radanovich, who represents Fresno, 
California, for 1 minute.
  Mr. RADANOVICH. Mr. Speaker, we are standing on the precipice of a 
major shift in this country's history. In less than a year, the Obama 
administration, working with the Pelosi Congress, has recklessly spent 
taxpayer funds to expand government to a level never before seen in 
history.
  The government is now more involved in our lives than I think any of

[[Page 27442]]

us could have imagined. The result has been double-digit unemployment 
for the first time since the early 1980s. And now we are going to vote 
on whether the government should take over the Nation's health care 
system at a cost of $1.3 trillion and up to 5.5 million jobs.
  Despite all this, the leadership of this Congress has chosen to 
ignore the will of the people and say, America, you are wrong. We know 
what's best for you.
  Well, this bill is not what the American people want, and it 
certainly is not what the doctor ordered for health care improvement.

                              {time}  1515

  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Illinois (Ms. Schakowsky), a senior member of the Energy and Commerce 
Committee.
  Ms. SCHAKOWSKY. This is a great moment in history because today we 
act to guarantee affordable health care for this and future 
generations. It is a great day for women. Our bill stops gender rating, 
preventing insurance companies from charging women 48 percent more than 
men for the same coverage.
  We eliminate preexisting conditions. Being a breast cancer survivor 
or domestic violence victim will no longer prevent access to care. We 
require coverage of maternity and well-baby care. We ensure that older 
women not yet eligible for Medicare can buy affordable coverage.
  We improve Medicare. Senior women will be able to afford preventive 
services like cancer screenings because we eliminate cost-sharing. We 
close the doughnut hole, so they can afford their medications.
  Women need health care reform. They need H.R. 3962.
  Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the 
honorable gentlewoman from North Carolina (Mrs. Myrick), a cancer 
survivor.
  Mrs. MYRICK. Mr. Speaker, Americans are struggling with health care 
costs. We all know that. Too many families can't afford coverage, and 
small businesses are struggling to find coverage for their employees.
  However, this bill does not fix the underlying problem, the cost of 
health insurance. It is an unprecedented expansion of Federal 
Government spending that will only dig a deeper hole of debt for 
generations to come.
  Margaret Thatcher once said, ``We want a society in which we are free 
to make choices, to make mistakes, to be generous and compassionate. 
Not a society in which the State is responsible for everything, and no 
one is responsible for the State.''
  The majority's bill creates a society that resembles the latter, and 
it is a mistake. I urge my colleagues to vote ``no.''
  Mr. WAXMAN. Mr. Speaker, can I inquire how much time is available on 
each side?
  The SPEAKER pro tempore. The gentleman from California has 13\1/2\ 
minutes remaining. The gentleman from Texas has 17\1/2\ minutes 
remaining.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Wisconsin (Ms. Baldwin).
  Ms. BALDWIN. Mr. Speaker, I rise in support of this bill, which will 
provide affordable health coverage to 36 million people who lack it 
today. This has been an aspiration for our Nation and our people for 
decades.
  I first ran for office motivated by my belief that every American 
should have access to quality health care, and I will not stop fighting 
until every American is covered. There are far too many daily reminders 
of the failures and injustices of our current system, the countless 
stories of bankruptcy, care delayed and premature death. And yet we 
have let years go by while people suffer.
  Today, we convene to debate and advance legislation that delivers 
meaningful insurance reform, outlawing outrageous insurance abuses, 
lowering costs, and extending coverage to all. I will cast my vote 
today on behalf of the people in Wisconsin and millions throughout 
America who have said enough is enough.
  Today, we declare with conviction: every American deserves health 
care, and every American shall have it.
  Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the 
sixth Frelinghuysen to represent a district from the Garden State of 
New Jersey, the Honorable Rodney Frelinghuysen.
  Mr. FRELINGHUYSEN. Mr. Speaker, I thank the gentleman for yielding.
  Mr. Speaker, I rise in opposition to this legislation because I have 
been listening to my constituents. Over the past several months, I have 
received over 13,000 letters, emails, faxes and calls from New Jersey 
families and employers. Unprecedented. I have listened to hundreds of 
residents in town hall meetings, retirement communities, nursing homes 
and senior clubs.
  I have visited areas hospitals and businesses, large and small. I 
have met with medical societies, health providers, doctors, nurses, 
anesthesiologists, home health aides, chiropractors, surgeons, all of 
them.
  In each of these meetings, these men and women have expressed deep 
concern about the so-called health care reforms that have been 
sponsored by the House majority, the Pelosi bill, and most are opposed. 
They are worried about how this massive bill, over 1,900 pages long, 
will affect their doctor-patient relationship, their personal care, and 
their ability to afford their health insurance. And they are worried 
with good reason.
  H.R. 3962 is a toxic-mixture of job-killing higher taxes, rampant new 
mandates on businesses and individuals of all ages and damaging 
Medicare cuts, combined with a government takeover of health care.
  It demands opposition on so many grounds:
  First, according to the Congressional Budget Office, H.R. 3962 will 
cost at least $1.2 trillion over the next ten years! This is mind-
boggling, on top of earlier borrowing and deficits!
  To pay for this massive new spending, Speaker Pelosi wants to raise 
taxes and cut Medicare that older Americans depend on each and every 
day.
  My colleagues, we heard the grim news yesterday that unemployment 
currently is at a 26-year high--10.2 percent. (And we know it's 
actually higher.) And yet, this bill contains $735 billion in new 
taxes!
  Using the formula developed by the chief White House economic 
advisor, 5.5 million Americans could lose their jobs as a result of 
enactment of the Pelosi Health Care bill.
  $735 billion in new taxes.
  Among the new taxes is a new ``surtax'' on high-income filers--many 
of whom are small business men and women.
  While this tax is intended to target ``high-income'' individuals and 
couples, it is not indexed for inflation, meaning it will reach 
millions more New Jersey residents over time just like the Alternative 
Minimum Tax.
  H.R. 3962 also includes taxes on individuals who do not purchase 
government-mandated health insurance.
  Think about this! You do not make enough money to afford health 
insurance and this bill actually fines you! The end result: you still 
don't have coverage and you've been fined as well!
  Young people will be particularly surprised that they will be subject 
to such a fine!
  Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the 
gentleman from Massachusetts (Mr. Frank) for the purpose of a colloquy.
  Mr. FRANK of Massachusetts. I thank the chairman, and I congratulate 
him for the excellent work he and others have done on this bill.
  I want to discuss the importance of the bill in addressing hard-to-
reach communities, including commercial fishermen, who are a very 
important part of my constituency, but also farmers and ranchers. 
Ranchers tend to be a less important part of my constituency.
  We are creating a new health insurance marketplace and requiring 
everyone to have coverage, which I support. This makes it particularly 
important to educate those that haven't had reliable, continuous access 
to quality, affordable health care.
  Under the bill, will the commissioner be able to contract with 
entities such as commercial fishing organizations or others to 
facilitate the dissemination of information?
  Mr. WAXMAN. The answer is yes.
  Mr. FRANK of Massachusetts. I thank the gentleman. I assume this 
means also the commissioner can work with the Small Business 
Administration on this sort of outreach and education?

[[Page 27443]]


  Mr. WAXMAN. Yes. The bill ensures the commissioner will work with the 
Small Business Administration.
  Mr. FRANK of Massachusetts. I thank the chairman for clarifying these 
points.
  Section 2229 of the Senate bill recognizes the unique health care 
educational outreach needs of commercial fishermen, farmers and 
ranchers, and I hope that that will be accepted in the final bill.
  Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the 
honorable gentleman from Pennsylvania (Mr. Pitts), one of the strong 
pro-life leaders in the U.S. Congress, a combat veteran of Vietnam, and 
a member of the Energy and Commerce Committee.
  Mr. PITTS. Mr. Speaker, there has been some recent confusion 
surrounding the inclusion of abortion coverage in H.R. 3962, but the 
issue is actually quite clear. The Capps amendment in the bill, which 
some have argued is neutral on abortion, explicitly authorizes the 
Federal Government to directly fund elective abortions using Federal 
funds drawn from a Federal Treasury account. The provision has been 
billed as a so-called compromise amendment. But this bill will 
radically expand current and longstanding Federal policy with respect 
to abortion.
  Currently, there is not a single government health care program that 
provides coverage for elective abortion; not SCHIP, not Medicaid, not 
DOD, Indian Health or the Federal Employee Health Benefit Program, all 
because of congressional action to explicitly prohibit coverage of 
abortion under each of these programs. But such an explicit exclusion 
is missing from this bill.
  Therefore, I urge my colleagues to support, when it comes up later, 
the Stupak-Pitts-Chris Smith-Ellsworth-Dahlkemper-Kaptur amendment that 
would prevent Federal funding of abortion in this bill.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Florida (Ms. Castor), a member of our committee.
  Ms. CASTOR of Florida. Mr. Speaker, Democrats will now deliver on 
what American families and businesses have been asking for when it 
comes to their health: one, meaningful, secure and stable insurance; 
two, improved Medicare for seniors; and, three, vital consumer 
protections.
  For families with health insurance, health reform will provide you 
with coverage you can count on. Families will no longer have to worry 
about insurance companies canceling their coverage because someone in 
their family gets sick. Health insurance companies will no longer be 
able to bar you from insurance just because you have diabetes or cancer 
or some other chronic condition.
  American families have been doing everything right. They have been 
paying their copays and paying their premiums, even as those costs have 
risen dramatically. Our health bill says that in return, that coverage 
must be meaningful, stable and secure. And for our family members who 
rely on Medicare, you will see immediate improvements, in your 
prescriptions, your checkups, and a provision I worked on, to penalize 
unscrupulous practices of private Medicare insurance sales agents.
  The meaningful health reform that will pass the House today builds on 
the great legacies of Social Security and Medicare, and I am proud to 
represent Florida families in this historic vote.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentlewoman 
from Wyoming (Mrs. Lummis), who represents the entire State.
  Mrs. LUMMIS. Mr. Speaker, I stand before you today on behalf of the 
people of Wyoming, where individual freedom and personal responsibility 
are hallmark values.
  This $1 trillion tax-everybody-right-down-to-the-wheelchair debacle 
will impact every person in Wyoming. This bill will force my 
constituents to buy insurance, whether it makes sense for them or not. 
This bill will dump some of my constituents into a government-run 
health care program to which Members of Congress will not even subject 
themselves.
  I sought an amendment that would allow States to shield their 
citizens from government-forced insurance, from taxes and possible 
fines or imprisonment, from government policies that come between 
themselves and their doctors, from unfunded mandates on States. But my 
amendment and dozens of others were swept away by the majority, and 
American freedoms right along with it.
  Our Constitution was designed to empower the American people and 
shackle the Federal Government. This bill will shackle the American 
people while empowering the Federal Government. It is a sad day for 
Wyoming, Mr. Speaker.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will remind all persons in the 
gallery that they are here as guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. WAXMAN. Mr. Speaker, I am pleased to yield 1 minute to the 
gentleman from Pennsylvania (Mr. Patrick J. Murphy), who has been a 
leader in our efforts to lower growth in premiums through measures such 
as immediate review and justification of insurance rate increases.
  Mr. PATRICK J. MURPHY of Pennsylvania. Colleagues, voting ``yes'' 
today means tax incentives for Joe Frederick, a small business owner in 
Bucks County, Pennsylvania, who struggles with skyrocketing health care 
costs for his employees. It is a vote for Mrs. St. Clair, whose niece 
died because she couldn't get insurance. It is a vote for Jay Doroshow, 
who was kicked off his plan after being diagnosed with Lou Gehrig's 
disease.
  I urge a ``yes'' vote for our fellow Americans who want to secure 
affordable health insurance which can't be taken away from them when 
they need it most.
  Sixteen years have passed since we last tried to reform health care. 
Premiums have more than doubled. Every day in the State of 
Pennsylvania, 510 families are kicked off their coverage. That is every 
single day.
  Mr. Speaker, as I said, I am a proud Blue Dog Democrat, and there is 
universal agreement that to get our country's fiscal house back in 
order, we must first get our health care spending under control. And 
this bill does just that. It actually reduces our deficit by $129 
billion, taking important steps to rein in health care costs.
  But there is more work to be done, and I look forward to working with 
you and our leadership to accomplish this goal.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. WAXMAN. Mr. Speaker, I yield the gentleman an additional 10 
seconds.
  If the gentleman would permit, I want to thank you for your 
leadership, and assure you we are going to continue to work in 
conference to do everything we can to make coverage affordable for the 
American people.
  Mr. PATRICK J. MURPHY of Pennsylvania. Thank you, and I urge my 
colleagues to vote ``yes'' today.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman 
from Nebraska (Mr. Terry), who represents Omaha, Nebraska, the home of 
the College World Series.
  Mr. TERRY. Mr. Speaker, it is clear that skyrocketing health care 
costs do exist, causing a number of Americans to become uninsured. But 
instead of addressing these issues, the Speaker has offered us a bill 
that dramatically overhauls the present health care system.
  It injects government into every corner of health care decision-
making, from arming the Health Choices Commissioner with unprecedented 
power to dictate coverage and influence costs, to imposing crushing 
taxes on small businesses. It transfers $600 billion from Medicare and 
Medicaid and imposes mandates on States by expanding Medicaid, which 
will then trickle down and force the States and the localities to 
increase taxes, really masking the true cost of this massive $1.2 
trillion bill.
  There is a better way that we can accomplish providing Americans with 
affordable health care.

[[Page 27444]]



                              {time}  1530

  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from 
Connecticut (Mr. Murphy).
  Mr. MURPHY of Connecticut. Mr. Speaker, every night in my State, 
thousands of kids go to sleep sick in their beds just because their 
mothers can't afford to get them to doctors. This is the most affluent, 
most compassionate Nation in the world, and it makes absolutely no 
sense that our health care system is the most inefficient, most unfair 
in the world. But to change this, we don't need to throw out what we've 
got.
  Despite all this nonsense political speak from the Republicans about 
government takeovers, this bill simply seeks to reset the rules of the 
private health care marketplace so that it starts working again like it 
should, so that small businesses can band together to negotiate for 
lower prices, so that individuals will have access to tax credits to 
help them pay for private insurance, insurance that's fair and doesn't 
discriminate against them because they're sick. We'll fix this crisis 
in our health care system all on the shoulders of a reformed private 
system so that never again does a child fall asleep sick in his bed 
because his country, the most powerful in the world, didn't have the 
coverage to make him well.
  Mr. BARTON of Texas. I would like to recognize the gentleman from 
Virginia, Congressman Frank Wolf, for a unanimous consent request.
  Mr. WOLF. I rise in strong opposition to the bill because our Nation 
is going broke.
  I rise in opposition to this bill.
  We must carefully weigh the implications of a costly new government 
spending program at a time when the country already owes more than $56 
trillion in entitlement obligations.
  I am also deeply concerned about the national debt, which has doubled 
since 2000 and is nearing $12 trillion for the first time in our 
history.
  Any plan put forward must control costs, not add billions of dollars 
to an already ballooning deficit.
  America is going broke. Is this the legacy this Congress wants to 
leave our children and grandchildren?

                              News Release

       ``Health care is a very personal issue and there are very 
     real consequences to what Congress does on this issue. 
     Congress must be committed to offering affordable, 
     accessible, and portable health care choices with the goal of 
     fixing what's broken and keeping what works. I know there are 
     good and reasonable people with deeply held views on every 
     side of the health care reform issue. That's why I believe 
     all sides need an opportunity to be heard and offer ideas so 
     that a bipartisan consensus can be reached.
       ``I believe every fair-minded person would agree that 
     Congress needs to find a way for the millions of Americans 
     without health insurance to be assured of quality, affordable 
     health care when they need it and to address the concerns of 
     those who are paying for a plan they believe falls short of 
     the coverage they need. Part and parcel of that discussion, I 
     believe, also must be the recognition that there are many 
     folks are paying for a health insurance plan that they like 
     and want to keep and they don't want the government involved 
     in their health care decisions.
       ``I am very concerned, however, about the health care 
     reform process under way in Congress. House Democrats on 
     October 29 unveiled a 1,990-page health reform bill--H.R. 
     3962--which is estimated to cost just under $900 billion over 
     10 years. Especially troubling is the majority leadership's 
     intention to fast track the legislation for House 
     consideration within days of its introduction.
       ``Congress needs to listen to the American people, take its 
     time and get health care reform legislation right. This is 
     too important an issue to rush through under some artificial 
     timeline. It is for this reason that I am cosponsoring a 
     resolution calling for any health care reform legislation 
     considered by Congress to be made available online in its 
     final form 30 days prior to being voted on in the House. I 
     believe that every American must have the opportunity to read 
     and understand what Congress is considering. Now with the 
     latest bill covering nearly 2,000 pages, that is more 
     important than ever. A copy of H.R. 3962 is available on my 
     Web page, www.wolf.house.gov.
       ``I opposed the first version of the Democrats' health 
     reform legislation (H.R. 3200) that was introduced this 
     summer, and nothing that I have read so far in the newest 
     version introduced on October 29 changes my view. This 
     legislation would set up a government insurance option with 
     rates to be negotiated between providers and federal health 
     officials. It has mandates for every American to have 
     insurance and for employers to provide insurance. It would 
     expand Medicaid to historic levels adding new mandates on 
     states. The revenue sources identified include a surcharge on 
     wealthy taxpayers and changes to Medicaid and Medicare which 
     would translate to about $500 billion in cost savings over 10 
     years, according to the Congressional Budget Office.
       ``When President Obama earlier this year directed Congress 
     to come up with a health reform plan, I had hoped that both 
     Republicans and Democrats could work together on this issue 
     of such complexity in a bipartisan way and reach consensus on 
     a plan to address the needs of uninsured Americans, protect 
     those with insurance plans they like, and keep a lid on 
     deficit spending at a time when our economy is reeling from 
     recession and spiking unemployment. What we have seen, 
     however, is the opposite. The speaker and House majority 
     worked alone on H.R. 3200 that initially was to be voted on 
     by the House in early August. They have continued to work 
     behind closed doors to refine that plan, and the latest bill, 
     H.R. 3962, was drafted solely by the majority.
       ``I don't believe that is the right way to develop public 
     policy on an issue of such importance and far-reaching 
     consequence to every American. This is a complex issue to 
     legislate, and there are legitimate questions that Congress 
     must answer. Among the many questions to be resolved are how 
     to make sure health care decisions are patient-centered and 
     remain between physicians and patients and not prescribed by 
     some government formula; how to provide for Americans who 
     don't have health insurance and ensure those with pre-
     existing conditions can get insurance; how to protect those 
     who have health insurance and don't want to be forced to give 
     up their plans or pay more for them; how to control health 
     care costs and pay for health care reform without increasing 
     the deficit; how to ensure that U.S. taxpayers are not 
     subsidizing health insurance for those illegally in our 
     country; how to ensure that the self-employed and small 
     business owners can afford insurance, and how to ensure that 
     young adults can continue to be carried under their parents' 
     health plan until they reach age 25.
       ``I have concerns about a government-run insurance option 
     and what that will mean in the way of costly mandates for 
     small businesses and other employers during a time when 
     unemployment is teetering near 10 percent. I am also 
     concerned about how Americans will pay for a $900 billion 
     plan as our country tries to work its way out of an economic 
     recession and faces trillions of dollars in debt and a 
     growing annual deficit that could be near $2 trillion. I also 
     have questions about finding a half trillion dollars in 
     savings in Medicare and Medicaid costs. What will that mean 
     for senior citizens today?
       ``We must carefully weigh the implications of a costly new 
     government spending program at a time when the country 
     already owes more than $56 trillion in promised entitlement 
     obligations through Medicare and Social Security. I'm also 
     concerned about the national debt, which has doubled since 
     2000 and is nearing $12 trillion for the first time in our 
     history, and unprecedented federal deficits, which could 
     result in increased interest rates for consumers if we 
     continue to finance government by borrowing from foreign 
     lenders. I have the leading bill in the House to establish a 
     bipartisan commission to review entitlement spending with tax 
     policy on the table to ensure that Congress addresses these 
     spending issues, which if left unchecked, will be disastrous 
     for future generations. (For more information about the SAFE 
     commission, go to www.wolf
.house.gov/SAFE.)
       ``I again want to emphasize: it is important for Congress 
     to fix what's broken with our nation's health insurance 
     system. But we have to do it the right way without changing 
     what is working. We need a plan that controls costs without 
     adding billions of dollars to an already ballooning deficit; 
     ensures competition and choice; provides that patients and 
     their doctors make the decisions on medical care rather than 
     a government-run agency, and addresses skyrocketing medical 
     liability costs and tort reform.
       ``I believe that the legislation in the House falls short 
     of those goals and that Congress has a lot more work to do to 
     provide the kind of health reforms Americans want and need.''

  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the former FBI 
man from the great State of Michigan (Mr. Rogers), a member of the 
committee.
  Mr. ROGERS of Michigan. Mr. Speaker, there are huge consequences to 
the 85 percent of Americans who have earned their health care in this 
bill. Not only will they get longer wait times and more expensive 
premiums, but at the end of that, with new debts, some $1.5 trillion in 
new spending, 18 million Americans won't have coverage. But more 
importantly, there will be another victim.
  There is nothing more sacred than the bond between a mother and a 
child,

[[Page 27445]]

that trust, that love, that nurturing when that child is sick. And when 
a mother goes to the doctor under that 2,000-page bill, that 
relationship that they enjoy between their patient and their doctor and 
what that mother wants for that child is no longer sacred, because now, 
through the 118 different boards and commissions, their comparative 
effectiveness research allows the Federal Government, through forced 
government insurance, to ration and deny care. You have violated the 
most important trust, the most important thing that we have in the 
building block and the foundation of the values of this country. That 
mother, that doctor knows what's best for that child. You will find no 
compassion in a Federal bureaucracy.
  Mr. Speaker, I would urge the strong rejection and the protection of 
that bond between doctor and patient and mother and child.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from 
Colorado (Mr. Salazar).
  Mr. SALAZAR. Mr. Speaker, I am especially pleased that this bill will 
help rural America. Currently, physicians in rural areas are reimbursed 
less from Medicare than their urban counterparts. H.R. 3962 will 
reimburse primary care physicians in rural areas 10 percent more than 
the urban physicians not only to equalize the disparity, but to make 
rural communities more attractive to physicians.
  Most of my district is considered a health professional shortage 
area. In my district in Colorado, we have three counties with only one 
practicing physician. We have one county with none at all. This bill 
will increase the number of physicians in all of my counties and 
improve access for 106,000 Medicare beneficiaries.
  This bill will expand insurance coverage to 111,000 currently 
uninsured residents in my district. In my district, it will protect 900 
families from going bankrupt due to excessive health care costs. It 
will help 184,000 low-income families pay for their insurance.
  Our current system is broken, and it is time to fix it now.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman 
from the Pelican State, Congressman Scalise from New Orleans, a member 
of the committee.
  Mr. SCALISE. I want to thank the ranking member from Texas for 
yielding.
  I rise in opposition to Speaker Pelosi's 1,990-page government 
takeover of health care. Weighing in at nearly 20 pounds, this bill 
comes out to over $530 million of spending per page. And where does 
this bill spend that money? Well, first of all, it fails the American 
people. It fails those small businesses and families that are going to 
have to pay the $730 billion in new taxes in this bill. It fails our 
seniors who have to deal with over $500 billion in cuts to Medicare. 
And it fails many of President Obama's own pledges and promises he made 
right here on this floor, like when he said, If you make less than 
$250,000 a year, you won't pay any new taxes, ``not a dime.''
  In this bill, there is over $20 billion of new taxes just on people 
who have no insurance. The President has said multiple times, If you 
like what you have, you can keep it. Unfortunately, this bill fails the 
President's promise because it allows the health care czar to take away 
your insurance even if you like it. It's so bad, that even when we 
brought our amendment to say all Members of Congress have to abide by 
this bill, they actually refused to allow a vote on that amendment.
  We need to defeat this legislation and do real reform.
  The SPEAKER pro tempore. The Chair would announce that the gentleman 
from Texas has 11\1/2\ minutes remaining, and the gentleman from 
California has 6\1/4\ minutes.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from 
Ohio, Betty Sutton, a member of our committee.
  Ms. SUTTON. Mr. Speaker, the American people have been waiting for 
this day, a day that we will finally pass a health care bill that will 
work for and with them, that will provide them with access to more 
affordable quality care, care that they can count on.
  Mr. Speaker, they have been waiting for us to put an end to the 
egregious discriminatory practices of insurance companies who deny 
coverage based on preexisting conditions and place caps on coverage to 
prevent people from accessing the care they need just when they need it 
the most.
  Today we act to improve the employer-based coverage for 420,000 
residents in my district, to improve Medicare for 107,000 
beneficiaries, and to move to close the prescription drug doughnut hole 
for seniors across this country.
  Yes, Mr. Speaker, the American people have been waiting, and today we 
act for a health care system that will work for and with them.
  Mr. BARTON of Texas. Mr. Speaker, could I ask how much time. You said 
it a minute ago, but I was not listening.
  The SPEAKER pro tempore. The gentleman from Texas has 11\1/2\ minutes 
remaining. The gentleman from California has 5\1/4\ minutes remaining.
  Mr. BARTON of Texas. Thank you, Mr. Speaker. I was listening to my 
distinguished friends on the majority raptly.
  I now yield 1 minute to one of our doctors, physicians, the gentleman 
from Lewisville, Texas, the Honorable Michael Burgess, also a member of 
the committee.
  Mr. BURGESS. I thank the gentleman for yielding.
  Last spring and summer, as we got into this debate, America's doctors 
were pretty clear of what they wanted to see if Congress was going to 
undertake health care reform. They wanted to see some relief in the 
medical justice system. They wanted to see some medical liability 
reform. They desperately needed a fix to the payment formula in 
Medicare that shows reductions in Medicare reimbursement rates every 
year for as far as the eye could see, and they wanted a little help 
with antitrust relief. After all, if we're going to ask our doctors to 
be our partners in this brave new world of health care reform, the 
least we could do is let them talk amongst themselves about the best 
way to deliver high-quality care at low cost.
  Well, what happened? Antitrust; not in this bill. SGR; we'll take 
that up at some point in the future. Medical liability; a smidgeon of 
medical liability reform in this bill, but nothing compared to what 
doctors actually need.
  In the last 6 years, Texas has done what this country needs to 
realize would be the way forward in medical liability reform. Caps on 
noneconomic damages have worked in the State of Texas. You don't have 
to take my word for it. There are almost 15,000 new physicians that 
have come to the State of Texas since 2003 when this was enacted. There 
are 82 counties that now have doctors which did not have them before. 
Emergency room services and OB services particularly have seen 
significant increases since Texas passed their sensible liability 
reform.
  Mr. WAXMAN. Mr. Speaker, for a unanimous consent request, I yield to 
the gentleman from Iowa (Mr. Boswell).
  Mr. BOSWELL. I rise in support of this bill. The people in my area 
are waiting and so is my State and our country.
  Mr. Speaker, I rise today in support of H.R. 3962, the Affordable 
Health Care for America Act.
  Today, I am pleased to vote for the most transformative piece of 
legislation that I have considered during my 13 years in Congress.
  I am voting to grant access to health care coverage for 18,000 
uninsured constituents in my district and to make it more affordable 
for another 440,000 insured.
  I am voting to guarantee that 6,400 of my constituents with 
preexisting conditions could never be denied coverage and to reduce 
insurance costs for 14,800 small businesses.
  I am voting to finally address how Iowa's hospitals and providers are 
reimbursed for the care they provide.
  Under this legislation, the Government will not force individuals and 
families with employer-based coverage to give up their insurance plans. 
However, as a result of the insurance reforms in this bill, they will 
no longer be required to pay co-pays or deductibles for preventive 
care; no more rate increases or coverage denials for preexisting 
conditions, gender, or occupation; and guaranteed oral, vision, and 
hearing benefits for children. The

[[Page 27446]]

public option offered in the health insurance exchange would drive down 
costs across the board by fostering competition and expanding insurance 
choices.
  Iowa's hospitals and providers have shouldered the burden of unfair 
Medicare reimbursements for the high-quality care they provide for too 
long. This bill will require studies on the reimbursement formula and 
move toward a payment system based on quality, not quantity. Providers 
who participate in the public option would be reimbursed through 
negotiated rates that balance what private insurance companies pay for 
services with the current Medicare rates.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from 
Virginia (Mr. Perriello) for the purpose of a colloquy.
  Mr. PERRIELLO. Mr. Chairman, I recognize the good things this bill 
does to make health care more affordable for families and expand access 
to preventive and wellness care. I just want to clarify for the record 
that maternity care is a required benefit in the essential benefits 
package for all individual insurance and employer insurance across the 
country.
  Mr. WAXMAN. If the gentleman will yield, yes, it is. That is a 
correct statement.
  Mr. PERRIELLO. And it is my understanding that prenatal and postnatal 
care is generally considered to be part of maternity care, as 
recognized by organizations such as the American College of 
Obstetricians and Gynecologists.
  Mr. WAXMAN. The gentleman is correct in that statement.
  Mr. PERRIELLO. Thank you, Mr. Chairman, for this clarification.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman 
from Phoenix, Arizona, Congressman John Shadegg, a member of the 
committee.
  Mr. SHADEGG. I thank the gentleman for yielding.
  This is Maddie. Maddie believes in freedom. Maddie likes America 
because we have freedom here, and Maddie believes in patient-choice 
health care. She asked to come here today to say that she doesn't want 
the government to take over health care. She wants to be able to keep 
her plan.
  You see, Maddie knows that if this bill passes, it says that her 
mom's health care goes away and won't be around in 5 years. As a matter 
of fact, the bill says, if the bill passes, then no more health care 
for her mom because it has to change.
  Maddie wants patient choice. Maddie doesn't want her mom's premiums 
to go up. She doesn't want her mom's taxes to go up by $730 billion, do 
you, Maddie? That's too much money. She doesn't want a health care bill 
that will cost $1.5 trillion. She wants America's health insurance 
companies to have to compete with each other.
  She believes in choice, but most of all, Maddie says, Don't tax me to 
pay for health care that you guys want. If you want health care, pay 
for it yourselves, because it's not fair to pass your health care bills 
on to me and my grandchildren.
  Thank you, Maddie.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The gentleman is reminded not to refer to 
guests of the House as props.
  Mr. WAXMAN. Mr. Speaker, that was a remarkable child and a great 
ventriloquist.
  I would like to yield for a unanimous consent request to the 
gentleman from Virginia (Mr. Boucher).
  Mr. BOUCHER. Mr. Speaker, I rise in opposition to the bill.
  Health care reform is needed. More than 36 million American citizens 
do not have health insurance, and millions more are underinsured and 
cannot afford to pay for the medical care they need. As those without 
insurance are treated in emergency rooms, the high cost of that care is 
borne by those who have insurance, driving up health insurance costs 
for everyone. The typical family pays an extra $1,100 each year in 
health insurance premiums as a cost of treating the uninsured. Health 
insurance premiums are increasing 3.5 times as fast as the rate of 
increase in family incomes.
  This status quo is unsustainable, and finding a way for everyone to 
afford health insurance is necessary to benefit both the uninsured and 
those who have insurance. I hope that following a House-Senate 
conference on the legislation, we will be able to send to the White 
House the needed reform measure.
  But reform legislation must ensure that Southwest Virginia residents 
continue to have access to the high quality health care services now 
delivered locally.
  I oppose the health care reform legislation now before the House for 
several reasons including the continued existence of disparities in 
Medicare reimbursements between urban and rural areas under the House 
bill. Rural areas have traditionally received less under Medicare than 
urban areas, and while the bill makes some improvements in this regard, 
I would like to see more done to increase the payments to rural health 
care providers. Higher Medicare reimbursements would enable the 
attraction of more doctors to serve our medically underserved region.
  I also oppose the bill because of my concern that a government 
operated health insurance plan could place at risk the survival of our 
region's hospitals. Most of our hospitals are operated on a non-profit 
basis for the benefit of the community. While most of their receipts 
are from Medicare and Medicaid payments, they lose money on each 
Medicare or Medicaid patient they treat. These programs reimburse 
hospitals at rates below the actual cost of providing patient care.
  The financial viability of our hospitals comes from the payments they 
receive from privately insured patients. A government operated health 
insurance plan competing with private insurance will attract patients 
who are privately insured today, with the result that the hospitals 
would treat less privately insured patients and lose the critical 
revenues that are essential to their survival.
  A government operated plan would reimburse health care providers at 
rates approximating Medicare rates, and hospitals would lose money on 
each of their patients insured under the government plan.
  I am concerned that for these reasons the creation of a government 
operated insurance plan as envisioned in the House bill could result in 
the closure of hospitals in our region. Families depend on our 
community hospitals for health care services, and financially healthy 
hospitals are essential to the health of Southwest Virginians.
  Many of our hospitals are financially stressed in normal times, and 
two hospitals in the district I represent closed for periods of time in 
recent years for financial reasons. The government owned insurance plan 
as outlined in the House bill could push many more over the edge. I 
cannot support legislation that could lead to that result.
  I also believe that bipartisan participation is needed on a measure 
of this scope which affects every American. The best ideas of Democrats 
and Republicans alike should be drawn upon to fashion the final 
legislation. That did not happen as the House bill was constructed.
  In July, I opposed the health care reform measure when it was 
considered by the House Energy and Commerce Committee and expressed my 
concerns at that time. The bill passed by the House did not address 
those concerns.
  Passage of the House bill is but a first step in a long legislative 
process to final enactment of a reform. I look forward to future steps 
in that process offering an opportunity for my concerns to be resolved.
  Reform is needed, and I hope to support the final passage of 
legislation that emerges from a House-Senate conference that creates 
affordable access to health care for all Americans and does so in a way 
that enables the continued delivery of the excellent care now offered 
in our region.
  Mr. WAXMAN. At this time, I yield 1 minute to the gentleman from the 
State of Maryland (Mr. Sarbanes), a member of our committee.
  Mr. SARBANES. Mr. Speaker, every day millions of people wake up with 
a knot in their stomach because they have anxiety and fear that they 
may lose their health care coverage or they don't have it to begin 
with. They need this health care bill. We in this Chamber are conscious 
of the sweep of history, but the people in my district and millions 
more across the country have a much less ambitious perspective. They 
just want to know is this a good bill, does it make sense, and will it 
help them and their families.
  Well, if you are a senior, the answer is yes. We're going to begin 
closing the doughnut hole. If you are a young person, the answer is 
yes. You can now stay on your parents' policy through age 26. If you 
are a working adult, the answer is yes, because we're going to curb the 
abusive practices of the health insurance industry.
  So what I want to say to people in my district and to others is this 
is a

[[Page 27447]]

good bill, it makes sense, and it will help millions of Americans 
across this country.
  I urge its passage.
  Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the 
gentleman from the Hoosier State of Indiana, Mr. Steve Buyer, another 
member of the Energy and Commerce Committee, and the ranking member on 
the Veterans' Affairs Committee.
  Mr. BUYER. Mr. Speaker, in a few days, all of us are going to be 
going back to our districts. We are going to be celebrating Veterans 
Day. Many of you are going to be giving speeches. You are going to be 
throwing your arms around the soldier, the marine, the sailor, the 
airman, the coastguardsman. Do you throw your arm around them in this 
bill? You don't.
  And when you go home and you give that speech, you can tap into the 
American character and you can say, Americans go to a land where 
they've never been to fight for a people that they've never met. They 
do so at no bounty of their own, and they leave freedom in their 
footsteps. Yet when they get to come home, how does our Congress right 
now treat them? In this 2,000-page bill, we deny them their rights of 
choice with regard to the health system which they can go to. Can you 
imagine that?
  Now, I received a pledge not only from the Speaker, but also from the 
leadership, that veterans would be taken care of in this bill. My 
amendments were denied last night in the Rules Committee. How do you 
deny veterans their choice in this bill?
  Shame on this institution.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair would again remind all persons in 
the gallery that they are here as guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the Rules of the House, and are 
asked to respect those rules.

                              {time}  1545

  Mr. WAXMAN. Mr. Speaker, I yield myself 1 minute.
  Before I yield to another very important member of our committee, I 
just want to set the record straight. We keep faith with the veterans 
in this bill. We allow them to keep their veterans benefits. We allow 
them to keep their benefits. They may, if they choose to, go into the 
exchange; but if they don't, they keep their benefits.
  Mr. BUYER. Will the gentleman yield?
  Mr. WAXMAN. I yield 1 minute to the gentleman from Iowa (Mr. Braley), 
a member of the Energy and Commerce Committee.
  Mr. BUYER. We do not. Mr. Speaker, we don't protect veterans' rights.
  The SPEAKER pro tempore. The gentleman from California controls the 
time and has yielded to the gentleman from Iowa.
  Mr. BUYER. * * *
  The SPEAKER pro tempore. The gentleman does not have the time. The 
gentleman from Iowa has the floor.
  Mr. BUYER. I ask that----
  The SPEAKER pro tempore. The gentleman is asked to respect the rules 
of the House.
  Mr. BUYER. I will.
  Mr. BARTON of Texas. Mr. Speaker, I will yield 1 minute to the 
gentleman, if that's allowed.
  The SPEAKER pro tempore. The gentleman from California has already 
yielded time to another Member.
  Mr. BUYER. Just protect veterans and I'll go sit down.
  The SPEAKER pro tempore. The Chair would ask that the gentleman abide 
by the rules of the House.
  The gentleman from Iowa is recognized.
  Mr. BRALEY of Iowa. I thank the chairman for his extraordinary 
leadership on this bill.
  Mr. Speaker, I rise today on the third anniversary of my election to 
Congress to urge my colleagues to speak truth to fear and vote for the 
Affordable Choices for America Health Care Act.
  We were elected, my class, to come and change the direction of this 
country. That's exactly what this bill does.
  We just saw a beautiful young child. I want to tell you about another 
beautiful young child, Tucker Wright, my nephew's son, who at age 18 
months was diagnosed with liver cancer, had two-thirds of his liver 
removed, and faces a lifetime of expensive medical care. Tucker was 
lucky because both of his parents work full time. Both of them have 
health care. And yet he still has tens of thousands of uninsured 
medical costs that his parents have to pay for.
  That is what's wrong with health care delivery in this country. 
That's why we need to reform health care. And that's why this bill will 
do for America what we should have done 100 years ago: provide health 
care for all Americans as a matter of right, not as a matter of 
privilege. And that's why I support this bill.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the 
distinguished ranking member of the Financial Services Committee from 
the great State of Alabama, Mr. Spencer Bachus.
  Mr. BACHUS. Mr. Speaker, when I joined the Army, they sent me to Fort 
Lewis, Washington; and one of the first things we did there was get in 
line to get our hair cut.
  We noticed on the wall there were pictures of four different 
haircuts, and they told us to choose one of those haircuts, get a 
number, and give it to the barber.
  We thought this was going to be pretty good. So we all gave him that 
number for the longest haircut. We all gave our numbers to the barber, 
and he cut all our hair off, every one of us. The numbers meant 
absolutely nothing.
  When we got back to the barracks, we knew who was in charge. We knew 
who was making the decisions, and it wasn't us. The Army was making all 
the decisions.
  Just like thinking you're going to get the haircut you choose, we're 
promised the right to choose under this bill. But the reality is, just 
like the Army, when the government's in charge, you're not. This bill 
is about a new government bureaucracy making all the choices for us.
  We're Americans. America is about freedom. Freedom is about making 
choices. And given the choice, I'll always put my faith in the 
individual, not the government.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from the 
State of California (Mrs. Davis) for the purposes of a colloquy.
  Mrs. DAVIS of California. Mr. Speaker, I appreciate the opportunity 
to raise this issue also on behalf of my colleague from California, 
Congresswoman Speier.
  Unfortunately, the provisions in section 309 allowing States to enter 
health insurance compacts may bring unintended consequences that could 
threaten long-established patient protections, and I know that that is 
not the intention.
  I certainly plan on supporting this legislation today; but I would 
ask you for the commitment, Mr. Chairman, to continue working on the 
language in section 309 to ensure it does not impact strong State 
consumer safeguards such as we have in California.
  Mr. WAXMAN. If the gentlewoman would yield, I thank you and I'm 
encouraged you and your staff have committed to further working on 
these provisions and not allowing health insurers to find loopholes in 
State laws.
  Mrs. DAVIS of California. Thank you, Mr. Chairman. I look forward to 
that.
  Mr. BARTON of Texas. Mr. Speaker, it is my privilege to yield 1 
minute to Congressman Fortenberry of Lincoln, Nebraska, which today, 
since Oklahoma is playing Nebraska at Lincoln, is the largest city in 
Nebraska.
  Mr. FORTENBERRY. I thank the gentleman for the insight.
  Mr. Speaker, our health care system must be strengthened. No one 
disputes the diagnosis. We need to improve health care outcomes for all 
Americans and reduce costs, especially for small businesses and 
families, while we protect vulnerable persons.
  But this bill is a massive, risky restructuring of our health care 
system. Why could there not be agreement on reasonable reforms such as 
portability of insurance, buying insurance across State lines, and 
creating new insurance association models for farmers and

[[Page 27448]]

families, providing affordable options just like corporations have?
  I agree we should promote a health care culture that focuses on 
wellness and prevention, removes lifetime caps, and expands high-risk 
pools to help those with preexisting conditions. However, I fear that 
this 2,000-page bill at $1.3 trillion will fail to reduce costs, would 
simply shift the costs to more government-run health care and reduce 
health care liberties.
  Mr. Speaker, what is at issue now is winning and power, not 
effective, reasonable reforms. We've missed an opportunity. I cannot 
support this bill.
  Mr. WAXMAN. Mr. Speaker, I reserve the balance of my time.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman 
from Lubbock, Texas, a recent beneficiary of the best health care 
system in the world, Congressman Randy Neugebauer.
  Mr. NEUGEBAUER. Mr. Speaker, I rise today as a proud cancer survivor.
  August 1 of this year, I was diagnosed with the early stages of 
prostate cancer. And thank goodness I live in America and I was able to 
sit down with my doctor and work out a treatment plan that would help 
me be cancer free and stand before you today. Thank goodness that I 
live in a country where I could go and see my doctor and make choices. 
And thank goodness I live in America where I didn't have to get on a 
list to determine when I was going to be able to have the surgery so 
that I could get rid of this cancer. Thank goodness I'm not living in 
Canada or Europe, the very system that our colleagues on the other side 
of the aisle are trying to model America's health care system on.
  I thought about during August a young lady named Candy Menville that 
was crying in her wheelchair and begging me to make sure that we didn't 
turn our health care system in America into the same system that's in 
Canada and Europe. She said, Congressman, with tears running down her 
eyes, don't take away my options.
  Mr. Speaker, don't take away Cindy's option and don't take away my 
options and others like me. Vote down this terrible bill.


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore (Mr. Salazar). The Chair will remind all 
persons in the gallery that they are guests of the House and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.


                         Parliamentary Inquiry

  Mr. BARTON of Texas. Parliamentary inquiry, Mr. Speaker.
  The SPEAKER pro tempore. The gentleman is recognized for a 
parliamentary inquiry.
  Mr. BARTON of Texas. We respect the ruling and the admonition about 
members of the gallery, but is it acceptable under the rules for the 
Members of Congress to show approval or disapproval of a speech on the 
floor?
  The SPEAKER pro tempore. It is acceptable unless interrupting another 
in debate.
  Mr. BARTON of Texas. Thank you, Mr. Speaker. We approve the Speaker's 
ruling.
  Mr. Speaker, it is now my privilege to yield 1 minute to the 
gentleman from the State of Oklahoma (Mr. Cole), and it is with great 
pleasure that I announce that the entire Oklahoma and Nebraskan 
delegation who disagree on the outcome of the football game are all in 
agreement in opposing this bill.
  Mr. COLE. I thank the gentleman for yielding.
  Mr. Speaker, the Oklahomans I represent oppose this bill because they 
know what it does and what it does not do.
  They know that this bill will raise taxes, not lower them. They know 
that this bill will grow government, not shrink it. They know that this 
bill weakens Medicare, not strengthens it. They know that this bill 
destroys jobs, that it doesn't create any. They know that this bill 
will force State governments to cut services and raise taxes, and it 
will put government bureaucrats rather than health care professionals 
in charge of their health care system.
  Oklahomans know this bill does nothing to reform our tort system. 
They know it does nothing to give individual purchasers individual tax 
deductions. They know it does nothing to establish national insurance 
markets and association health plans that would allow small business to 
provide affordable insurance to their employees.
  Oklahomans know the Pelosi health care bill is a giant step backward. 
And every Oklahoman in Congress will vote against this bill.
  Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from 
Maryland (Mr. Cummings).
  Mr. CUMMINGS. Mr. Speaker, this afternoon we've heard a lot of people 
saying we should do what our constituents say that we should do.
  I ask them what do I say to the gentleman in my district who is 
suffering from cancer and who is now trying to choose between eating 
and paying a high copayment for chemotherapy?
  What am I to say to the young writer who for years paid her premiums 
and then, when she got pregnant and had her baby, they gave her a 
present on the way out the door that she could not afford: a $22,000 
bill?
  What do I say to a lady who suffered from breast cancer in my 
district and when she lost her job, lost her insurance, could not get 
insurance, could not get it because of something called preexisting 
conditions?
  I would say to all those folks who are saying that we do not need 
this and must not do this, we have a moral authority to our fellow 
citizens. A moral authority.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to one of our pro-
life leaders, the Honorable Chris Smith of New Jersey.
  Mr. SMITH of New Jersey. Mr. Speaker, today the House has an 
opportunity to significantly limit public funding of abortion in a 
manner that replicates the Hyde amendment and applies it to the two new 
massive government health care programs created in the pending bill: 
the public option and affordability credit program.
  The Stupak-Pitts amendment ensures that pro-life Americans will not 
be forced to fund, enable, or facilitate the killing of unborn children 
and the wounding of their mothers.
  Supermajorities, more than 67 percent, oppose public funding of 
abortion. Protecting vulnerable unborn children and women from the 
insidious violence of abortion is the human rights cause of our time.
  So please let's not gloss over or trivialize the fact that abortion 
dismembers, decapitates, starves to death, or chemically poisons 
innocent babies, and that the abortion act itself, euphemistically 
called ``choice,'' can in no way be construed to be compassionate, 
benign, nurturing, or health care. Abortion is violence against women 
and children. It is neither health care nor reform.
  Support the Stupak-Pitts amendment
  Mr. WAXMAN. Mr. Speaker, I continue to reserve the balance of my 
time.


                         Parliamentary Inquiry

  Mr. BARTON of Texas. Mr. Speaker, I have a parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state his inquiry.
  Mr. BARTON of Texas. Who has the right to close this part of the 
debate? Does Chairman Waxman have the right to close or does the 
ranking minority member have the right to close?
  The SPEAKER pro tempore. There is only one overall right to close, 
and that will be the majority manager.
  Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to Congressman Jeb 
Hensarling from the great State of Texas for 1 minute.

                              {time}  1600

  Mr. HENSARLING. Mr. Speaker, government-run health care is 
government-rationed health care. Today in America when our loved ones 
need health care, they wait hours, maybe days; but in Britain and 
Canada, they wait weeks, months, perhaps even a year.
  Mr. Speaker, since I have been age 5, I have gone fishing with my 
father. Those are moments I treasure. But 15 years ago he went to see 
his doctor about a chest pain; 48 hours later, he

[[Page 27449]]

had triple bypass surgery. And guess what? At age 81, we are still 
fishing. But had he been in Britain, had he been in Canada, there might 
never have been another fishing trip. My children might have never 
known their grandfather because health care delayed is health care 
denied.
  Government-rationed health care will mean our loved ones will suffer. 
They will languish, and perhaps even perish. We should never support a 
children-bankrupting, health care-rationing, freedom-crushing $1 
trillion government takeover of our health care system.
  Let's support the Republican plan to give the American people the 
health care they need, when they need it, at a price they can afford.
  Mr. BARTON of Texas. Mr. Speaker, I would like to recognize a Member 
from the great State of Georgia (Mr. Kingston) for 1 minute.
  Mr. KINGSTON. Mr. Speaker, in January, with unemployment at 8.5 
percent, Speaker Pelosi passed an $800 billion pork-ladened stimulus 
bill that was supposed to create jobs. In May, with unemployment up to 
9.5 percent, Speaker Pelosi passed an energy tax of $1,500 on every 
household in America that was supposed to create green jobs. Now in 
November, unemployment is up to 10.5 percent, we have the highest 
deficit in the history of the country, a $12 trillion national debt, 
and Speaker Pelosi wants to spend $1 trillion on a government takeover 
of insurance.
  This bill raises premiums. It raises taxes. It cuts Medicare, and it 
forces you to surrender your current health care coverage and puts a 
thousand bureaucrats in between you and your doctor.
  The government couldn't even run Cash for Clunkers, and now it wants 
to take over 17 percent of the economy.
  Let's vote ``no'' on the Pelosi plan and support the bipartisan 
alternative.
  The SPEAKER pro tempore. The gentleman from Texas has 1\1/2\ minutes. 
The gentleman from California has 30 seconds.
  Mr. BARTON of Texas. Mr. Speaker, I yield myself the balance of the 
Energy and Commerce time.
  Mr. Speaker, first of all, let me tell you how proud I am of the 
members of the Energy and Commerce Committee on both sides of the aisle 
who have participated in this debate since January, and who have 
participated on the floor debate today. It makes me proud to be a 
member of that committee.
  Mr. Speaker, we have heard all of the policy arguments pro and con 
for this bill. I am going to end the Republican side of the Energy and 
Commerce debate simply by saying that I think this bill should be 
defeated because it is an imposition on personal freedom here in 
America. I just simply don't think that it is right to tell people that 
they have to have insurance, tells employers they have to provide 
insurance, to set up a bureaucracy that advises a bureaucracy what that 
insurance should be, that then determines what the insurance itself 
should be, what the minimum premium should be, what has to be covered, 
what shouldn't be covered, and then over time almost guarantees that 
everybody, except the richest people in America, are in some version of 
the public option.
  I just think that is wrong in America, Mr. Speaker, and for that 
reason alone I am against this bill.
  There is an alternative. The Republican alternative covers many of 
the things that my friends on the majority side say they are for. We 
simply do it without mandating and imposing government will on the 
American people. Please vote ``no'' on the majority bill, and vote 
``yes'' on the minority substitute.
  Mr. WAXMAN. Mr. Speaker, 37 million Americans do not have health 
insurance because they can't afford it, their employers do not offer it 
to them, or they have a preexisting condition and the insurance 
companies deny it to them. We want them to buy the same policies that 
our Republican Members have talked about in such glowing terms, 
available to them and their families. Don't say ``no'' to 37 million 
Americans and tell them they have freedom. They don't have freedom to 
go without. In a country where people should not be forced into 
bankruptcy when they get sick, let's let people buy private insurance 
or a public option and get coverage.
  The SPEAKER pro tempore. The gentleman from New York (Mr. Rangel) has 
40 minutes and the gentleman from Michigan (Mr. Camp) has 40 minutes.
  The Chair recognizes the gentleman from New York.
  Mr. RANGEL. Mr. Speaker, I would like to take this time to recognize 
the gentlewoman from Florida (Ms. Wasserman Schultz) for 1 minute.
  Ms. WASSERMAN SCHULTZ. Mr. Speaker, we have heard a lot of discussion 
in this debate about the uninsured and the uninsurable. Often it is 
easiest to think about people with preexisting conditions who are 
uninsurable as the poor, the sick, or the jobless.
  Mr. Speaker, the face of the uninsurable stands before this House 
today in this well. As a breast cancer survivor, the sad reality of 
today's health care system is if I lost this job tomorrow, I could not 
buy health insurance coverage because I have a preexisting condition.
  This bill will end all that. The Affordable Health Care for America 
Act will make it possible to rid our country of the angst of facing 
illness without coverage. Passage will mean that Carol from south 
Florida won't face the dual tragedy of a cancer diagnosis and the loss 
of her job and, thus, the loss of her health care coverage. So instead 
of putting all of her energy into fighting cancer, like I could, Carol 
had to fight for her health care coverage, too.
  It is time to deliver on the American promise not just of liberty, 
but justice for all.
  Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
  Republicans have listened to the American people. It is clear from 
the Speaker's health care bill the Democrats have not. The Speaker 
crafted this bill behind closed doors and added 1,000 pages that have 
never been before a committee or had any input from the American 
people.
  Just yesterday we confirmed that Americans could face 5 years in jail 
if they don't comply with the bill's demands to buy approved health 
insurance, and who knows what else we will discover over time. Simply 
put, the health care of the American people is too important and too 
complex to risk on this gigantic gamble. This bill will do lasting 
damage to our economy and force millions of Americans to give up their 
current health care coverage.
  With the national unemployment rate spiking to 10.2 percent, it 
should be unthinkable to pass this bill which contains more than $730 
billion in taxes that will destroy millions more American jobs. The 
Democrats' bill cuts Medicare by one-half trillion dollars, slashing 
health care benefits for seniors, a direct violation of the President's 
pledge that Americans could keep what they have if they like it.
  The Democrats' bill, when paired with an unpaid-for SGR fix, 
increases the deficit, a violation of the President's pledge that 
health care reform would not add one dime to the debt. The Democrats' 
bill drives up the cost of health care and increases Federal spending 
on health care by $600 billion, a violation of the President's pledge 
that health care reform would bend down the cost curve.
  So you can't keep what you like if you like it. The bill spends over 
$1 trillion while raising taxes, cutting Medicare and increasing the 
deficit, and it drives up the cost of health care. The Democrat 
majority has not listened to the American people. Vote ``no'' on this 
bill.
  Mr. RANGEL. Mr. Speaker, I would like to recognize the distinguished 
gentleman from Georgia (Mr. Scott) for 1 minute.
  Mr. SCOTT of Georgia. Mr. Speaker, today the arc of history will 
hover over this House of Representatives, and the question facing each 
and every one of us today as 14,600 of our American citizens are losing 
their insurance every day is: where are we going to stand on this arc 
of history today? I ask you, are you going to stand with the negative 
forces of ``no'' or ``kill the bill'' or ``I object''? Or are we going 
to stand with the hope of America that has been expressed all of the 
way down from Teddy

[[Page 27450]]

Roosevelt to Franklin Delano Roosevelt to Harry Truman to Lyndon Baines 
Johnson to Teddy Kennedy, and to John Dingell?
  I say to you today, this House of Representatives, stand up and say I 
am not afraid of the future because the key to our future is to make 
sure that all Americans have access and have affordable health care 
insurance. That's what the American people are expecting us to do, to 
stand up for America.
  Mr. CAMP. I yield to the gentleman from California for a unanimous 
consent request.
  Mr. ROHRABACHER. Mr. Speaker, I oppose this bill that will take 
hundreds of billions of dollars out of Medicare and give billions of 
dollars of health care to illegal immigrants.
  Mr. Speaker, this attempt at sliding Americans into dependence on a 
government-controlled health care system brings bait and switch to a 
new low.
  We have heard about the flaws of our current healthcare system, high 
costs, lack of portability, lose a job--lose health insurance, 
discrimination of those with preexisting conditions. Yes, many of the 
heart-wrenching stories we are hearing to justify this legislation are 
real. But correcting those maladies requires specific reform, not 
transforming healthcare in America into a bureaucratically-managed 
system that will cost hundreds of billions, including billions to 
provide healthcare for illegal aliens, while at the same time cutting 
Medicare by hundreds of billions of dollars. This so-called reform will 
destroy the freedom of the American people to make health decisions 
with a doctor of their choice. It will transform our system, rather 
than reform it. And what we will end up with is a system that is 
massively more expensive, less effective, and will be based on 
government controls and rationing, rather than the patient-doctor 
relationship.
  You can touch our hearts with the stories of suffering brought about 
by defects in our current system, but it doesn't follow that we have to 
buy into this monstrous federal power grab. It is too benign to call 
this scheme bait and switch.
  Wake up America!!
  This bill cuts healthcare for our seniors by hundreds of billions of 
dollars while providing subsidized health care of illegal immigrants, 
which will draw more illegals into our country.
  Wake up America!!
  This bill is structured so that private companies will find it 
profitable to dump employees into the government-run option, rather 
than continuing to offer private health insurance.
  Wake up America!!
  This ill-conceived power grab will bankrupt our country as it 
destroys our freedom.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, a true American hero, the gentleman from 
Texas (Mr. Sam Johnson).
  Mr. SAM JOHNSON of Texas. Mr. Speaker, today we are voting on Speaker 
Pelosi's $1 trillion Washington takeover of health care. This bill 
bulldozes individual liberty and puts the government just where it 
doesn't belong, right smack dab in the middle of your personal health 
care decisions. This bill forces every single person in this country to 
purchase government-approved health care or go to jail. Businesses must 
also offer government-approved health care or face hundreds of billions 
of dollars in job-killing taxes.
  Unfortunately, government-approved health care will be defined by a 
handful of bureaucrats around a conference table in Washington. This 
unprecedented Washington power grab eliminates an individual's right to 
choose what kind of health care is best for them and their families.
  Speaker Pelosi's 20-pound, 2,000-page bill costs $2.2 million per 
word. The American public have made their voices heard. They are sick 
and tired of the government sticking its nose where it doesn't belong. 
They are fed up with Washington's trillion-dollar bailouts, free 
handouts and special interest paybacks.
  The Democrats in Congress need to listen and come up with a 
bipartisan, patient-centered plan. We can do better with a targeted, 
fiscally responsible approach that makes health insurance more 
affordable, more accessible, and available. Real health reform protects 
a patient's right to choose their own care. Real health reform gives 
doctors the freedom to do what is best for their patients. We can do 
all of this without piling trillions of dollars of debt onto our 
children and grandchildren.
  Vote down this deficit-ballooning, job-killing, Washington takeover 
of health care today.
  Mr. RANGEL. Mr. Speaker, I would like to recognize my friend and 
colleague, the outspoken Member from New York, Mr. Nadler, for 1 
minute.
  Mr. NADLER of New York. Mr. Speaker, I have spent much of my adult 
life fighting for greater health care rights and for universal health 
coverage. This historic bill goes a long way toward achieving those 
goals.
  Around the country, we see millions of people with inadequate or no 
coverage. Families go to sleep at night knowing that they are one 
serious illness away from bankruptcy. And the unemployed are people who 
face going it alone in the prohibitively expensive individual coverage 
market or, worse, going without insurance at all.

                              {time}  1615

  While I would have preferred a single-payer system, I am happy to 
support a bill that contains a public health insurance option that will 
provide competition to the private insurance companies and will drive 
down rates.
  This bill will end discrimination against people with preexisting 
health conditions, will end the practice of dropping patients when they 
are sick, and will strengthen and enhance Medicare by ending the 
doughnut hole and extending the solvency of the Medicare Trust Fund.
  Mr. Speaker, the status quo is not an option. We have an opportunity 
to get universal health care coverage in this country to implement the 
competitive public health insurance option that puts the patient before 
the quarterly financial report, and to ensure that just because you 
lose your job, you won't lose your health insurance.
  This is monumental and historic, and I am proud to support the 
Affordable Health Care for America Act.
  Mr. Speaker, I have spent much of my adult life fighting for greater 
health care rights and universal health coverage. This historic bill, 
H.R. 3962, makes great strides toward achieving those goals.
  Around the country, we see millions of people with inadequate or no 
coverage, with another 14,000 Americans joining the ranks of the 
uninsured each day. We see families who go to sleep at night knowing 
they are one serious illness away from bankruptcy, the reason for 55 
percent of all bankruptcies filed last year. We see the rising ranks of 
the unmployed who face going it alone in the prohibitively expensive 
individual coverage market--or worse, going without insurance at all. 
And we see 20,000 people die every year because they have no health 
insurance.
  At the same time that this stark reality hits hardworking Americans, 
insurance companies have conspired to keep costs high. These costs, 
upward of 15-35 percent squandered on outrageously high administrative 
costs, do nothing to make people healthier but do much to line the 
pockets of insurance companies and help their corporate bottom line.
  This is unacceptable. We must take action. That's why I support the 
Affordable Health Care for America Act.
  As with any legislation, there have been some compromises made along 
the way. I would have preferred a single payer system, the most 
effective and least costly way to implement a health delivery system. 
But I, like so many of my colleagues, have come to see a competitive 
public option as the best available way to refocus our misguided health 
care approach. A public option will put patients and doctors, not 
corporate bottom lines, at the forefront. This public option will add 
much needed competition into an insurance market that must be kept 
honest, and it will work to drive down rates.
  Mr. Speaker, this past August, political pundits and TV-talking heads 
had the public option dead on arrival. Yet, because of the efforts of 
progressive Members in Congress, in which I was proud to join, we 
succeeded in keeping the public option in this bill and ensured that 
the American people would be given an alternative to corporate health 
insurance. And make no mistake about it--the public option weathered 
the storms of misinformation, slander, and downright lies because the 
American people saw through the political game playing and saw the 
public option for what it is--an option, not a mandate, that will help 
stem the cost of ever-rising health care costs.

[[Page 27451]]

  In addition to the public option, this national health reform bill 
implements key insurance industry reforms, strengthens Medicare, and 
immediately gives hope to the millions of Americans currently living 
without health insurance.
  It will end discrimination against pre-existing conditions, and end 
the cruel practice of rescission, which allows insurance companies to 
drop people from coverage if their illness is considered too expensive. 
This bill also guarantees that people with insurance will not face 
devastating costs when they get sick by placing limits on out-of-pocket 
medical expenses, and creating, for the first time ever, a voluntary 
long-term care program. And H.R. 3962 would end the blanket exemption 
insurance companies currently enjoy from anti-trust laws. With this 
change, we can now bring anti-trust enforcement against the egregious 
practices of price-fixing and market allocation.
  H.R. 3962 contains numerous provisions that help our seniors by 
strengthening and enhancing the Medicare program. This bill reduces the 
donut hole to $500 immediately and eliminates it entirely by 2019. It 
allows the HHS secretary to negotiate prescription drug costs, which I 
have long advocated for, eliminates out-of-pocket expenses for 
preventive care for seniors, and extends the solvency of the Medicare 
trust fund for at least five years.
  Small businesses also receive desperately needed assistance from this 
bill. Initially, businesses with up to 25 employees, then growing to 
businesses with up to 100 employees by 2015, will be able to join the 
health exchange, which will allow small business employees to take 
advantage of group rates and a broader range of insurance options--a 
key change that will go a long way toward helping small businesses keep 
down their number one expense, which is the cost of providing health 
care coverage.
  For America's young people, who make up 29 percent of the uninsured 
in America, H.R. 3962 will permit parents to extend coverage to their 
children until their 27th birthday.
  To help American families defray the costs of health coverage, this 
bill extends assistance on a sliding scale to families earning up to 
$88,000 per year. This will go a long way toward ending the cruel 
choice between health care coverage and other necessities.
  Mr. Speaker, there are some who have said that health care reform is 
too hard. There are those who have allowed misinformation and politics 
to push them to root against helping their fellow Americans to have 
access to quality, affordable health care. There are even those who, 
for reasons I fail to grasp, want to continue with the status quo.
  To those people, Mr. Speaker, I say--the status quo is not an option. 
We have a remarkable opportunity in front of us. We have an opportunity 
to make fundamental changes to the way we view health care and deliver 
services, to implement a competitive public health insurance option 
that puts the patient before the quarterly financial report. And, with 
passage of this bill, we will be able to say for the first time in this 
country that just because you lose your job, you won't lose your health 
insurance.
  Mr. Speaker, this is monumental. This is historic. And I am proud to 
cast my vote in favor of the Affordable Health Care for America Act.
  Mr. CAMP. At this time, I yield 2 minutes to the distinguished 
gentleman from the Ways and Means Committee, the gentleman from Texas 
(Mr. Brady).
  Mr. BRADY of Texas. Mr. Speaker, this is the Pelosi health care plan, 
and it's wrong for America. Over 100 new Federal agencies, commissions, 
and mandates standing between you and your doctor.
  This huge, inefficient new bureaucracy makes your health care 
insurance more expensive, forces millions of Americans into a 
government-run plan, raises taxes on workers and small businesses, 
increases Medicare drug costs for seniors, adds billions to our 
frightening deficit, and after throwing $1 trillion at the problem, 
still leaves 18 million Americans uninsured. Big government doesn't 
mean better health care.
  To pay for this massive new bureaucracy, Democrats slash Medicare for 
our elderly by a half-trillion dollars. That means 660,000 Texas 
seniors are going to lose their plan. It shuts 40 doctor-owned 
hospitals in Texas, costing us 15,000 jobs. And 1.5 million Texans will 
have their plans disappear.
  This is not the reform families need. Instead, this is all about 
taking the giant first step toward a single-payer national health care 
system. If the Pelosi plan passes, Washington will ultimately decide 
which doctors you can see, what treatments you deserve, and what 
medicines you receive, and when you're sick, will you be worth their 
cost?
  House Republicans have a different vision. We listened. Ours is a 
careful, step-by-step solution to the complex issue of health care, 
focusing first on lowering your health care costs so more can afford 
it. We have no tax increases, no Medicare cuts, no rationing, no 
mandates, no huge intrusion of government into the most intimate parts 
of your health care, just more choices, more fairness, less lawyers. 
Best of all, our Republican plan is the only reform that actually 
lowers your health care premiums and lowers the deficit.
  We need to get health care reform right the first time. The Pelosi 
plan is wrong.
  Mr. RANGEL. Mr. Speaker, for another view of health care in Texas, I 
yield 1 minute to Ms. Jackson-Lee.
  Ms. JACKSON-LEE of Texas. Mr. Speaker, today I am holding up a 
concise, efficient, and effective health care plan for America, H.R. 
3962, and I plan to stand with America and those who don't have health 
insurance today as we cast our vote for affordable health care for 
America.
  Eighteen thousand people die every year because they do not have 
health insurance. The State of Texas has 6 million people who don't 
have health insurance. Several Republican Members from Texas, have in 
their districts, some 29 percent, and 18 percent of individuals who 
don't have health insurance.
  So today I rise to say that the plan we have will immediately close 
the doughnut hole for Seniors. It will provide the uninsured with a 
bridge to the exchange program. It will extend the coverage for our 
young people until the age of 27, and, yes, I'm proud of the language 
on pages 22 and 23 that will begin to help save hospital beds in 
physician-owned hospitals in the State of Texas and around the Nation. 
This language is in the bill and we now can continue to work competent 
quality hospitals in rural and urban areas.
  We are ready to fight. We are ready to make sure that those who need 
health insurance will have us on their side. I am standing with America 
and voting for America for the first time in which a health care reform 
bill passes the House with a Public Option to give more access to 
Americans and lowers the costs of health care insurance. Vote for the 
health care bill now.
  I rise before you today in support of H.R. 3962, the Affordable 
Health Care for America Act. On July 5, 1965, President Lyndon Johnson 
said the following about the passage of Medicare, ``This bill is 
sweeping in its intent and impact. It will help pay for care in 
hospitals. If hospitalization is unnecessary, it will help pay for care 
in nursing homes or in the home. And wherever illness is treated--in 
home or hospital--it will also help all Americans.'' My friends we can 
all say that about this sweeping legislation. Madame Speaker, while 
some say that patients and physicians oppose this bill I know 
otherwise. Today, I met with dozens including physicians, medical 
students, patients, and advocates. This group included representatives 
from Doctors for America, National Physicians Alliance, American 
Medical Student Association, US PIRG, Disciples of Christ, Episcopal 
Church, NETWORK--A Catholic Social Justice Lobby, United Church of 
Christ, and United Methodist Church along with a nationally renowned 
cardiac surgeon Dr. Salim Aziz of the George Washington University 
Medical Center.
  The health providers with whom I met are on the front lines of the 
health care debate every day. As such, it is no surprise that they 
enthusiastically endorse this bill, while holding out hope for 
progressive changes to health reform legislation before it becomes law. 
These health professionals see the pain and frustration of hardworking 
Americans who face financial collapse, physical suffering, and 
sometimes the loss of their life simply because they do not have decent 
health care coverage.
  Allow me to share with you some of the stories that I've heard from 
these care givers. One story was that of Dr. ``Alex'', a Pediatrician 
and Health and Evidence Policy Fellow at Mt. Sinai School of Medicine. 
Dr. Alex told me of an illness he suffered himself while still a 
medical student at Howard University College of Medicine here in 
Washington, DC. One summer, during an internship at the Centers for 
Disease Control in Atlanta, Dr. Alex became very sick, and was examined 
at an

[[Page 27452]]

emergency room. The examination revealed that Dr. Alex's ailment arose 
from acute kidney failure.
  Dr. Alex thankfully had health coverage through Howard University's 
student health insurance plan. Yet he was faced a conundrum since the 
university's plan only covered health services required by their 
students in Washington, DC. It didn't cover him in Atlanta, thus Dr. 
Alex qualified as under-insured. Aware that he could not afford out-of-
pocket payment for a renal dialysis unit as was being recommended, by 
his physician, his father drove him through the night from Atlanta, 
waking him every few minutes to make sure he was responsive, until they 
finally reached Washington, DC, the next morning, where he could get 
the treatment needed. This story is proof of the fact that even those 
who chose to enter the profession of caring for others are not immune 
to the dysfunction of our health care system. Dr. Alex also related 
another interesting paradox that I'll share with you. He trained in 
pediatric medicine at a county hospital outside of Los Angeles. At this 
county hospital I cared for uninsured children, and those enrolled in 
SCHIP and Medicaid. What he most enjoyed about working within that 
system was that they provided high quality care to those who needed it 
the most. His patients on Medicaid and SCHIP were able to easily see 
sub specialists: Dermatologist, Ophthalmologist, and Gastro-intestinal 
physicians. His patients who had private insurance often faced health 
care barriers which his patients on SCHIP and Medicaid never had to 
navigate. When children who had private medical insurance visited his 
county hospital pediatric clinic, staff there had to seek preapproval 
from the private insurance company so that patients' parents were not 
billed and required to pay the cost of care out-of-pocket. In this 
county pediatric clinic he once cared for a 9-month-old boy who had a 
swollen face covered in a rash on his forehead and cheeks, and raw in 
his neck folds. He sat before him and scratched his arms, trunk, and 
face uncontrollably to the point of bleeding. Because of his constant 
scratching his skin had started to harden. He had uncontrolled eczema 
and his mother told him in tears how she had not been able to obtain a 
referral to a dermatologist. The county pediatric dermatologist's one 
afternoon a month clinic time was that same day. To prevent the 
patient's mother from receiving a large medical bill, Dr. Alex did what 
he normally did; he got on the phone to her private insurance company 
and asked the insurance bureaucrat to agree to pay for the visit. As 
his other patients had to wait for him, he wasted time on the phone 
trying to solicit preapproval from her insurance company. But he could 
not sway the insurance gatekeeper. He tried his hardest to make this 
bureaucrat understand the child's bloody scabs, the mother's tears. But 
to no avail. The dermatologist took pity on the child and did what we 
physicians often do, he saw the patient for free.
  Why have we allowed insurance bureaucrats to come between Dr. Alex 
and his patients? We can do better than allow profit driven bureaucrats 
decide what medicines my patients receive. He wants a health care 
system where when he writes a prescription his patient does not have to 
worry whether their insurance company will pay for it. An insurance 
bureaucrat sitting in their cubicle should play no part in the 
relationship between me and my patient. We need to reform our system.
  Today is a historic day not only for the 39 million uninsured 
Americans, but also for our great Nation. As Speaker Pelosi remarked 
earlier today, we, Members of Congress, are ``humbled to stand here at 
a time when we can associate ourselves with the work of those who 
passed Social Security, those who passed Medicare, and now we will pass 
health care reform.'' Many parallels exist between that history and 
today. Today, we listened to a parade of Republicans warn that this 
bill will bring the downfall of American society, of the American way 
of life. This is not the first time that the Republicans have been on 
the wrong side of history. In an interview in 1975, David L. Kopelman, 
who played a prominent role in the early administration of the Medicare 
Program, remarked that his colleagues were often criticized by 
Republicans. ``Communist,'' he recalled, ``was the designation all too 
liberally applied to anyone with a progressive idea. Well, after all, 
when we went around making contact with employers in those early years 
that was the designation not delicately applied by many, if not most of 
them, to the social security program. It must be some communist scheme 
foisted on the American people.'' Alf Landon, the Republican candidate 
for President in 1936, even campaigned on the fact that not a dollar in 
social security benefits would ever be paid.
  Mr. Speaker, unfortunately, such ad hominem attacks are as prevalent 
as ever. The Republicans want you to believe that our country is 
descending into an abyss of socialism, but nothing could be further 
from the truth. Today, I am proud to support a bill that is distinctly 
American. We the people, Thomas Jefferson wrote in the Declaration of 
Independence are endowed ``with certain unalienable Rights that among 
these are Life, Liberty and the pursuit of Happiness.--That to secure 
these rights, Governments are instituted among Men, deriving their just 
powers from the consent of the governed . . .'' I believe that it is no 
coincidence that life is listed first--for without it, the Founders 
realized, no other rights can be realized. Over years, the millions of 
Americans who could not access medical services were denied their most 
basic right. The value of life is echoed in the Universal Declaration 
of Human Rights as well as in the Hippocratic Oath taken by every 
physician.
  True, health insurance is not a human right by itself, but consider 
the following: according to the National Academy of Sciences, Institute 
of Medicine, there is a ``consistent and statistically significant 
relationship between health insurance coverage and health outcomes for 
adults. These factors, in turn, improve the likelihood of disease 
screening and early detection, the management of chronic illness, and 
the treatment of acute conditions . . .'' This year, a study published 
in the American Journal of Public Health by researchers at Harvard 
University Medical School concluded that nearly 45,000 excess deaths of 
Americans can be linked each year to lack of health insurance. Forty-
five thousand is fifteen times the death toll at the World Trade 
Center; 45,000 people are approximately equal to the population of 
Texas A&M University; 45,000 is almost thirty times the number of 
American soldiers killed in Iraq since 2001. The lives lost at the 
World Trade Center and in Iraq will never be forgotten. Why then, do we 
pretend that a far greater loss of life every year does not exist? Make 
no mistake about it, health insurance can be a direct determinant of 
whether somebody lives or dies.
  According to the U.S. Census Bureau, 27 million American live without 
health insurance, and an additional 1.1 million part-time workers lost 
their health insurance in 2008. Implementing this legislation will 
instantly improve the life expectancy of millions of Americans of all 
ages. It is impossible to put a price on that. When we talk about the 
right to healthcare, we are actually talking about the right to access 
healthcare. In our current system people do not choose to be uninsured 
but, instead, are priced out of insurance. These people cannot, as free 
market proponents often argue, ``Pull themselves up by their 
bootstraps.'' Instead, they and their families are too often cyclically 
and systemically trapped in their economic situation. Texas, in 
particular, with 6 million uninsured persons and 26 percent in the 18th 
Congressional--H.R. 3962 must pass.
  I am committed to working with the Speaker's office and Senatorial 
leadership now that we are taking the first step in stemming the rising 
tide of the many uninsured. The protection of physician-owned hospitals 
is an issue of national interest. We have a lot of work to do as we 
move toward the Senate and to the conference. I was gratified to meet 
with the Speaker today to discuss the continued protection of the very 
viable physician-owned hospitals.
  I will continue to work to save physician-owned hospitals that are 
currently treating patients or under significant development, to ensure 
that Americans can continue to receive healthcare at the local 
hospitals they have come to depend upon. Physician-owned hospitals take 
care of patients covered by Medicare and Medicaid, as well as patients 
who are uninsured or cannot pay for their care. They also provide 
emergency departments access for their communities. At a time when we 
are concerned about the shortage of hospital beds in the face of 
epidemics like the swine flu, my amendment to this landmark bill will 
make sure no hospital is forced to shut its doors or turn away Medicare 
or Medicaid patients. The benefits that will come from our efforts to 
protect physician owned hospitals are far reaching and will prevent any 
further losses to local economies. Not only do physician hospitals 
deliver high quality medical care to the patients they serve, they also 
provide much needed jobs, pay taxes, and generate significant economic 
activity for local businesses and communities. Existing physician-owned 
hospitals employ approximately 51,700 individuals, have over 27,000 
physicians on staff, pay approximately $2,421,579,312 in payroll taxes 
and $512,889,516 in other federal taxes, and have approximately $1.9 
billion in trade payables. Hospitals currently under development would 
employ approximately 21,700 more individuals. With approximately 50 
physician-owned hospitals, Texas leads the

[[Page 27453]]

nation in the number of physician-owned hospitals. The Texas economy 
could lose more than $2.3 billion and more than 22,000 jobs.
  In my district, the 18th Congressional District of Houston, Texas, 
St. Joseph Medical Center is a general acute care hospital that treats 
all patients. In fact, its 40 percent Medicaid patient population is 
double the average hospital's patient population in the entire State of 
Texas and is one of the highest in the country. St. Joseph's was 
operated by the Sisters of Charity for many years until it was 
scheduled to be closed because the order could no longer support it. 
The hospital was offered to for-profit and not-for-profit hospital 
systems but no one would accept responsibility for operating St. 
Joseph's. A plan was developed to convert the hospital into 
condominiums. I refused to allow that to happen. It was only at that 
point that the physicians who had practiced there for many years came 
together to buy the hospital to save it from closing.
  St. Joseph's takes care of patients covered by Medicare and Medicaid, 
as well as patients who are uninsured or cannot pay for their care. The 
emergency departments of many physician-owned ``specialty hospitals'' 
have been criticized for not having a true emergency department. St. 
Joseph's has a department which is open 24 hours per day, 7 days per 
week, providing an access point for patients in need of emergency 
services. In fact, St. Joseph's admissions through the emergency 
department are double the State average;
  St. Luke's hospital in Houston, which is church-owned, has three new 
facilities under development; the nonprofit religious mission has the 
controlling interest. One full-service hospital has one phase already 
operating, but would be under the growth restrictions; the hospital 
cannot be completed if the new restrictions apply. The hospital brought 
approximately 300 new jobs to the community; and
  Baylor Health Care System, based in Dallas, has found that their 
partnership with physicians has increased measurable quality, increased 
patient satisfaction, and decreased the cost in the delivery of their 
excellent care. This joint venture model has produced a heart hospital 
that has the lowest readmission rate in the entire United States. And 
yet this bill would deny Baylor Health Care System the right to add a 
single operating room or procedure room to meet its community's need. 
During the moratorium on physician-owned hospitals some years ago, 
Baylor wanted to add a badly needed OB/GYN service at its Frisco, 
Texas, hospital. This service is a money losing service, but there was 
no such service within many miles for those people--Baylor fulfilled 
the need. It was prohibited from adding this service simply because the 
hospital had physicians holding a minority of the ownership of the 
hospital. After the moratorium was lifted, the service was added and is 
currently working at its capacity.
  Mr. Speaker, can we imagine witnessing an impact, of no patient beds, 
6- to 8-hour waiting times, to extend even to 10-hour waiting times, 
turning emergency patients away at the door? Can we imagine the 
dramatic case, when patients are not able to have access to quality 
care? This is true of the most serious trauma, of the most serious 
medical cases. Physician owned hospitals serve in many cases at least 
40 percent of the city's population. I don't just mean the city's 
population. We are discussing a population that is between 500,000, 
which is the indigenous population, and the population of 1.5 million 
that's in the city every day.
  When a hospital downsizes in a particular city, it extends beyond the 
boundaries of that city, and in doing so, with this hospital being 
downsized, it's impacting all of the hospitals, not only in the city, 
but those hospitals in nearby jurisdictions. We're seeing the epicenter 
of a catastrophic event, and unless we realize the importance of this 
one medical facility, but look at it not from the perspective that it 
serves this city, but we have to realize that it serves the world. It 
serves the Nation. At the very least, it serves the Nation; at the very 
most, it most serves the world. So when you start looking at it from 
those perspectives, then it becomes more than just a problem of 
Houston, Texas, but a problem of this Nation. And it should be 
addressed in that manner.
  If we do not work closely together to look deeper at this issue, we 
will face a number of medical facility closures that is a disservice to 
the American people. So, we see that there seems to be a phasing-back 
or cutback in all of the major services, but the most important of 
those services, which directly affect the health and well-being of the 
citizens, or again, those 1.5 million people who visit and work in the 
city every day. So, we hear the same thing time and time again, even 
though individuals are saying that the patient caseload can be handled 
by the surrounding hospitals. You need but step into any emergency room 
on any day, at any time, and just see the impact of this one hospital 
being downsized. The impact will reach out throughout the city of 
Houston.
  Again, a true indication of the success of any city government, or 
any country, is its ability to care for its weak, its injured, its 
sick, its young, and its old. The ability to care--compassion. Let us 
be honest--we see the faces of those individuals who we cannot help, 
because the system has failed them, and they ask us for help. What do 
we tell them? You never want to lie to a patient. You want to be honest 
and up-front with this patient. But you reach a point where, in some 
cases, it's best that you say nothing.
  How can we tell a family member sitting across from me, in the back 
of my ambulance, with their loved one lying on the cot as we do CPR, 
cardiopulmonary resuscitation, on them, ``Ma'am, I'm sorry, we're going 
to have to go on the other side of the city because St. Joseph's 
Hospital is closed''? Then, when we get there, the doctors come to the 
family member and say, ``I'm sorry, your husband, your son, your 
daughter, your child, has died.''
  How do we explain that to them: We passed the hospital that may have 
made the difference in this case. The ability to care, to show 
compassion: It's just apparent to me that that just doesn't exist now. 
To sign off on anything less is to simply say, we turn our back on the 
community; we turn our back on the Nation. To do that, is to give away 
what makes us human. I think now is the time that we make that 
decision: Whether we are unwilling to turn away from what makes us 
human, or give in to those individuals who seek to benefit from others' 
miseries. Those individuals know who they are. I think now is the 
calling time. Now the horn is being blown, and we've got to answer. But 
first, the failure of every part of civilization is first, the 
inability to care for its population. From there, it tends to go 
downhill.
  This is a national problem, but we should be setting the trend, we 
should set the example for the entire Nation that hospitals like St. 
Joseph's Hospital do more than just care for our sick and injured. They 
represent our capacity to care. There is a duty to act and a passion to 
care.
  H.R. 3962 is a bill that will change the health dynamics positively 
for all Americans--but it is a work in progress. In the manager's 
amendment after weeks of meeting with the leadership our efforts to 
seek some relief for physician-owned hospitals was achieved. It is not 
a winning formula, however on pages 22-23 of the manager's amendment we 
secured language that says that all physician-owned hospitals should 
not be treated alike. I have introduced two amendments to cover 
extending the grandfathering in of physician-owned hospitals and on 
criteria for other physician-owned hospitals. However, our work is not 
finished--we must work with the Senate and in conference to keep 
quality health care.
  For the Record, I have attached a chart on Texas uninsured, benefits 
for the 18th Congressional District, and physician-owned hospitals.
  This is a vital issue which must be corrected or the bill moves 
through Congress and for physician-owned hospitals to survive and grow. 
Martin Luther King, Jr. often told the story of the priest, the Levite 
and the good Samaritan. ``The first question that the priest and Levite 
asked was ``If I stop to help this man, what will happen to me?'' But, 
the Good Samaritan reversed the question ``If I do not stop to help 
this man, what will happen to him?'' Today, we can be the Good 
Samaritan--to help all Americans access good health care. Finally a 
special thanks to Chairmen Rangel, Waxman, and Miller and a very, very 
thank you to Congressman John Dingell and the late Senator Edward M. 
Kennedy.
       No insurance. Texas has the highest rate of uninsured with 
     about 6 million uninsured.
       Texas Districts with the highest percentage of uninsured 
     constituents. Rank shows district ranking out of 435 
     nationally.
       Rank, Representative, district No., and percent uninsured:
       1. Ruben Hinojosa, District 15--46.4 percent.
       5. Gene Green, District 29--36.4 percent.
       6. Henry Cuellar, District 28--34.1 percent.
       8. Silvestre Reyes, District 16--33.3 percent.
       12. Eddie Bernice Johnson, District 30--32.3 percent.
       19. Sheila Jackson Lee, District 18--29.7 percent.
       22. Solomon Ortiz, District 27--28.6 percent.
       23. Louie Gohmart, District 1--26.9 percent.
       24. Jeb Hensarling, District 5--26.8 percent.
       27. Ciro Rodriguez, District 23--26.4 percent.
       Other South Texas Districts:
       37. Lloyd Dogget, District 25--25.0 percent.
       40. Charlie Gonzalez, District 20--24.7 percent.

[[Page 27454]]


       48. Ron Paul, District 14--23.7 percent.
       124. Lamar Smith, District 21--18.3 percent.

  Benefits of the Affordable Health Care for America Act in the 18th 
                    Congressional district of Texas

       The Affordable Health Care for America Act will make health 
     care affordable for the middle class, provide security for 
     seniors, and guarantee access to health insurance coverage 
     for the uninsured--while responsibly reducing the federal 
     deficit over the next decade and beyond. This analysis 
     examines the benefits of the legislation in the 18th 
     Congressional District of Texas. Congresswoman Sheila 
     Jackson-Lee represents the district.
       In Congresswoman Jackson-Lee's district, the Affordable 
     Health Care for America Act will:
       Improve employer-based coverage for 279,000 residents.
       Provide credits to help pay for coverage for up to 186,000 
     households.
       Improve Medicare for 70,000 beneficiaries, including 
     closing the prescription drug donut hole for 5,300 seniors.
       Allow 16,600 small businesses to obtain affordable health 
     care coverage and provide tax credits to help reduce health 
     insurance costs for up to 14,600 small businesses.
       Provide coverage for 187,000 uninsured residents.
       Protect up to 500 families from bankruptcy due to 
     unaffordable health care costs.
       Reduce the cost of uncompensated care for hospitals and 
     health care providers by $49 million.


   Affordable and Improved Health Care Coverage for the Middle Class

       Better health care coverage for the insured. Approximately 
     41% of the district's population, 279,000 residents, receive 
     health care coverage from their employer. Under the 
     legislation, individuals and families with employer-based 
     coverage can keep the health insurance coverage they have 
     now, and it will get better. As a result of the insurance 
     reforms in the bill, there will be no co-pays or deductibles 
     for preventive care; no more rate increases or coverage 
     denials for pre-existing conditions, gender, or occupation; 
     and guaranteed oral, vision, and hearing benefits for 
     children.
       Affordable health care for the uninsured. Those who do not 
     receive health care coverage through their employer will be 
     able to purchase coverage at group rates through a health 
     insurance exchange. Individuals and families with an income 
     of up to four times the federal poverty level--an income of 
     up to $88,000 for a family of four--will receive 
     affordability credits to help cover the cost of coverage. 
     There are 186,000 households in the district that could 
     qualify for these affordability credits if they need to 
     purchase their own coverage.
       Coverage for individuals with pre-existing conditions. 
     There are 27,600 individuals in the district who have pre-
     existing medical conditions that could prevent them from 
     buying insurance. Under the bill's insurance reforms, they 
     will now be able to purchase affordable coverage.
       Health care and financial security. There were 500 health 
     care-related bankruptcies in the district in 2008, caused 
     primarily by the health care costs not covered by insurance. 
     The bill caps annual out-of- * * *.
  Mr. CAMP. Mr. Speaker, at this time, I yield 2 minutes to the 
distinguished ranking member of the Budget Committee and distinguished 
member of the Ways and Means Committee, the gentleman from Wisconsin 
(Mr. Ryan).
  Mr. RYAN of Wisconsin. Mr. Speaker, I would like to place in the 
Record a statement commending the people at CBO for their long hours 
and hard work.
  Mr. Speaker, I firmly believe that this is probably the most 
consequential vote each of us will take in our service here, whether 
you've been here for 40 years or for 1 year.
  When you expose this bill's budget gimmicks, does it increase the 
debt and deficit? Yes. Will it take coverage away from seniors, raise 
premiums for families, and decrease health care innovation? Yes. Will 
it raise taxes on small businesses and workers and cost us nearly 5.5 
million jobs when our unemployment rate is 10.2 percent? Yes. Does this 
bill mean the government will take over running our health care system? 
Yes.
  But what is worse is this bill replaces the American idea with a 
European-style social welfare state. This bill, more than any other 
decision we are going to make in this body, will do more to put 
millions of Americans as dependents of a state rather than being 
dependent upon themselves.
  This is not about health care policy. If it were, we could pass a 
bipartisan bill to fix what's broken in health care without breaking 
what's working in health care. This is about ideology.
  My friends, the choice is not whether you're going to stick with your 
party leaders. The choice here is what side of history do you want to 
be on? Will you be on the side of history where you stick with the 
people and the principles that built this exceptional Nation? That is 
the choice we are going to make with this bill, and I encourage you to 
think it through.
  It is unusual for the House to be in session working on a Saturday. 
That has not been the case for the Congressional Budget Office's staff 
that has been working on health care legislation. For the past several 
months, CBO has worked non-stop to analyze health care legislation. 
This legislation is enormously complex and far-reaching and CBO is 
doing their best to fulfill their mission to provide objective non-
partisan analysis to the Congress. That analysis is critically 
important to us and I want to acknowledge the hard work of Director 
Doug Elmendorf and the following CBO staff in that endeavor:

       Alexandra Minicozzi, Allison Percy, Andrea Noda, Anna Cook, 
     April Grady, Athiphat Muthitacharoen, Ben Page, Bruce 
     Vavrichek, Assistant Director for Health and Human Resources.
       Carla Tighe Murray, Chapin White, Christi Hawley Anthony, 
     Colin Baker, Daniel Kao, David Auerbach, David Austin, David 
     Weiner, Doug Elmendorf, Director.
       Elizabeth Bass, Ellen Werble, Heidi Golding, Holly Harvey, 
     Deputy Assistant Director for Budget Analysis, Jamease 
     Kowalczyk, James Baumgardner, Deputy Assistant Director for 
     Health, Janet Holtzblatt, Jean Hearne.
       Jodi Capps, Joyce Manchester, Unit Chief, Long Term 
     Modeling Group, Julia Christensen, Julie Lee, Julie Somers, 
     Julie Topoleski, Kate Massey, Unit Chief, Low-Income Health 
     Programs and Prescription Drugs Cost Estimates.
       Keisuke Nakagawa, Kirstin Nelson, Kurt Seibert, Lara 
     Robillard, Leo Lex, Unit Chief, State and Local Government 
     Cost Estimates, Lisa Ramirez-Branum, Lori Housman, Lyle 
     Nelson, Matt Schmit, Matthew Goldberg, Assistant Director for 
     National Security.
       Mike Carpenter, Mindy Cohen, Noah Meyerson, Noelia 
     Duchovny, Patrick Bernhardt, Paul Burnham, Paul Jacobs, Pete 
     Fontaine, Assistant Director for Budget Analysis.
       Phil Ellis, Unit Chief, Health Policy Analysis, Rebecca 
     Yip, Robert Stewart, Sarah Jennings, Sean Dunbar, Sheila 
     Campbell, Stephanie Cameron, Stuart Hagen, Sunita D'Monte, 
     Susan Labovich, Tom Bradley, Unit Chief, Health Systems and 
     Medicare Cost Estimates.

  Mr. RANGEL. Mr. Speaker, I couldn't agree with the last speaker more. 
This is an historic moment, and I certainly hope you, your friends, and 
colleagues think this through for the American people.
  At this time, I have the pleasure to present to the body Mr. Lacy 
Clay, the gentleman from Missouri, and yield him 1 minute.
  Mr. CLAY. I thank the distinguished chairman for yielding.
  Mr. Speaker, I rise today to support a monumental piece of 
legislation that will expand health care coverage and reduce cost.
  Currently, 46 million Americans are uninsured, and by 2019 the number 
could reach over 65 million. Too many are denied access to care, often 
when they need it most. No one should be denied coverage because of a 
preexisting condition, and no one should have to fear losing their 
coverage after they get sick. Even individuals who have health 
insurance suffer. Millions of underinsured Americans pay exorbitant 
fees for procedures and treatments that their insurance plan should 
cover.
  The status quo is not working for Americans. It is time to take 
action. Each Member in this body should ask themselves one question 
before they vote, and that is: Am I my brother's keeper? And my answer 
is: Yes, I am.
  Mr. CAMP. I yield 2 minutes, Mr. Speaker, to the distinguished member 
of the Ways and Means, the gentleman from California (Mr. Herger).
  Mr. HERGER. Mr. Speaker, today I rise not only on behalf of my 
constituents in northern California, but on behalf of all Americans. 
They have made their opposition to government-run health care known. 
They have come out by the thousands to town halls, called our offices, 
and held peaceful rallies, but, unfortunately, congressional Democrats 
have refused to listen.
  The legislation being considered today is one of the most damaging, 
destructive bills ever to come before this Chamber. A government 
takeover of health care won't bring down cost, but it will bring down 
quality of care. It

[[Page 27455]]

will explode the national debt at the expense of future generations. It 
raises taxes by $750 billion and guarantees middle class tax increases 
down the road.
  We all agree that we need health care reform, but we don't need to 
put the government in charge. Mr. Speaker, I believe in the free 
market, I believe in choice and competition, and I believe in freedom 
to choose your doctor and to get the treatments you need. America was 
built on these principles, and the Pelosi health care plan will take us 
in the opposite direction.
  I urge every Member of the House to live up to our obligation, listen 
to the people and say ``no'' to government-run health care.
  Mr. RANGEL. I yield myself 30 seconds, Mr. Speaker, because the 
gentleman who just spoke said that the Democrats didn't listen to the 
Republicans. Having had the honor to serve with outstanding Republicans 
on the Ways and Means Committee and having, as chairman, had hearings 
last year and throughout, quite frankly, there wasn't much to listen to 
until last Tuesday when, for the first time, you presented a bill. In 
any event, I appreciate the gentleman's contribution.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. RANGEL. I yield myself such time as I may consume.
  We have been designated as one of the three committees to work on 
this bill for the President and for the House of Representatives. And 
we were privileged to work with Chairman Waxman as well as Chairman 
Miller. I don't think in the history of the Congress we have found 
three separate committees working in such cooperation. But as I said 
earlier, we had such hardworking, dedicated members and such a strong 
support staff that it's almost embarrassing that they are so limited in 
sharing with you the work and the time and support that they've given 
to this important issue for the Congress and for our country.
  In any event, I have to admit, as Chair, there was one member that I 
relied on so much. He is the gentleman from California who since 1984 
served and continues to serve as the chairman of the Health Committee. 
And so it is with a great deal of pride that I yield 3 minutes to the 
gentleman from California (Mr. Peter Stark).
  Mr. STARK. Mr. Speaker, today's vote will be the most important of 
our careers. History will mark which side we're on: providing quality, 
affordable coverage for all Americans, or the status quo.
  I would remind my friend from Wisconsin that former Senator Bob Dole 
voted against Medicare, and that vote has haunted him ever since. It 
probably prevented him from becoming President.
  Since my first election, I have worked to see that government serves 
our people. My top priority for 37 years has been to provide quality, 
affordable health care for all. I wish we had done it sooner, but at my 
age, you learn to take what you can when you can get it.
  The bill is not the bill that many of us would have created on our 
own. That is the legislative process. The compromise before us today is 
the right thing to do for the American people.
  The bill guarantees health coverage to 96 percent of Americans. It's 
fully paid for. People who like their coverage indeed can keep it. It 
reforms health insurance regulation and requires shared responsibility 
by individuals, businesses, and government. It assures that health care 
is affordable for lower- and middle-income families. It fills the 
Medicare prescription drug doughnut hole, and it provides free 
preventive services in Medicare.
  It has the support of consumers, doctors, nurses, senior citizens, 
children, people with disabilities, farmers, and small business 
owners--organizations that represent virtually every segment.
  In my district, like every other district, Republican or Democrat, 
I've got 67,000 uninsured people who will be helped; 8,000 people with 
preexisting conditions; 14,000 businesses will get tax credits; 8,300 
seniors will have the doughnut holes filled. And every district in the 
country has similar numbers. I defy you to go home and tell those 
people you voted to deny them quality, affordable health care.
  I am proud to have helped author this legislation. I encourage each 
of my colleagues to join me in voting ``yes.'' I can assure you, these 
guys aren't going to have to pay for it in the future.

                              {time}  1630


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. Members on both sides of the aisle are 
reminded not to use guests of the House as props.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to the distinguished member 
of the Ways and Means Committee, the gentleman from Georgia (Mr. 
Linder).
  Mr. LINDER. I thank the gentleman for yielding.
  Mr. Speaker, we have been listening ad nauseam for months from the 
Democrats, who have been saying that anybody who doesn't support a 
government takeover of health care is supporting their insurance 
friends or their friends in the pharmaceutical industry.
  Guess who contributes to political campaigns? Lawyers contribute more 
than all the rest together. To who whom do they give their money? 
Surprise. Surprise. Ninety-six percent was given to Democrats in this 
year. Is that why they are left out of the health care reform bill?
  Everyone who has looked at this issue for years has said to start 
with tort reform. Start with tort reform. The three most recent studies 
all this year said that Americans are spending $200 billion a year on 
tests and procedures that are unnecessary, defensive medicine, because, 
if they are not done, the doctors will be sued. That's $2 trillion over 
10 years. That would pay for this $1.5 trillion behemoth.
  It is ignored except in one fashion: there is mention in this bill 
that, if your State has already reduced jury awards and has gotten 
control over tort reform, you will be punished.
  Ladies and gentlemen, this is not about health care. This is about 
rewarding your friends and about punishing your enemies. It has been 
going on all year, and it is a huge mistake.
  Mr. RANGEL. Mr. Speaker, it is my pleasure to yield 1\1/2\ minutes to 
the gentleman from Michigan (Mr. Levin). If there is a moral issue, I 
would like to be on his side.
  Mr. LEVIN. Mr. Speaker, most Americans--and I emphasize that--most 
Americans want to keep the insurance they have and do not want to lose 
it because of skyrocketing costs; to be sure they are not denied 
coverage because of preexisting conditions; and to be sure if they have 
major illnesses, they are not bankrupted by unaffordable costs. Most 
Americans also want other citizens to have their health care needs 
covered by insurance.
  Democratic health care reform responds to these concerns, and like 
Social Security and Medicare, it is as American as apple pie.
  Consider this letter from a constituent of mine from Fraser, 
Michigan: ``I am ashamed to let my family and friends know that I have 
no health insurance. I have refused hospital treatment I know I needed 
because I could not afford to pay for any type of medical procedure.''
  She closes her letter with this simple message: ``Please don't let 
anything or anyone stop you from reforming health care. I hope you will 
think of me. I need you to do the right thing. Health care for all 
Americans now.''
  That's what we are doing: health care for all Americans now.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentleman from California (Mr. 
Nunes).
  Mr. NUNES. Mr. Speaker, as we consider this massive government-run 
health care bill currently before the House, I would like to remind my 
colleagues of a few things that have happened over the last year.
  We spent $1 trillion to bail out banks, investment companies and car 
companies. We spent another $1 trillion on a stimulus bill that has yet 
to produce any jobs as promised. This record spending doesn't count the 
omnibus spending bill that we had and the fact that we grew our budget 
to $3.6 trillion all in one year.

[[Page 27456]]

  If this weren't enough, we are being asked now to create a new 
trillion-dollar, government-run health care program despite the fact 
that we can't pay for the two existing government programs that we have 
today--Medicare and Medicaid. These two programs have at least $62 
trillion in debt that this Congress refuses to recognize. Let me repeat 
that again: $62 trillion in debt that we face with our two existing 
government-run health care programs. Mr. Speaker, with $1 trillion here 
and $1 trillion there, pretty soon, you are talking about real money.
  What is worse is that, despite all of this spending during record 
times of high unemployment, this bill will kill American jobs, 
exporting them overseas. In the meantime, our government leaders 
continue to run over and grovel to the Chinese to borrow more money to 
finance the spending.
  Mr. Speaker, Rome is burning while this Congress fiddles. This 
Congress is so irresponsible, so reckless, it's like watching a broke, 
drunk gambler continuing to double down, just trying to break even.
  Vote ``no.''


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will remind persons in the gallery 
that they are here as guests of the House and that any manifestation of 
approval or disapproval thereof of proceedings or other audible 
conversations is in violation of the rules of the House.
  Furthermore, occupants of the gallery are guests of the House. Those 
in violation of these rules of the House may be removed.
  Mr. RANGEL. Mr. Speaker, I yield 90 seconds to the gentleman from the 
sovereign State of Georgia (Mr. Lewis), the true voice of justice in 
this Congress.
  Mr. LEWIS of Georgia. Mr. Speaker, I want to thank my chairman, 
Chairman Rangel, for yielding.
  Mr. Speaker, this is a historic day. As President Kennedy said in his 
book ``Profiles in Courage,'' there comes a time when men must act 
according to the dictates of their conscience and not according to 
political expediency.
  We have a mission. We have a mandate. We have a moral obligation to 
lead this Nation into a new era where health care is a right and not a 
privilege. Now is the time. Be on the right side of history, the right 
side of the sick, the right side of the vulnerable. We have been 
tracked down by the spirit of history. If we fail to act on health 
care, if we fail to do what we must do, history will not be kind to any 
of us.
  So I say to you, my colleagues: be not afraid. Be not afraid. Be of 
the courage. The time is always right to do what is right. On this day, 
at this moment, answer the call of history, and pass health care 
reform, and pass it today. Pass it now for the people of this country.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to the gentleman from Texas 
(Mr. Carter).
  Mr. CARTER. Mr. Speaker, a couple of weeks ago, I was doing a town 
hall meeting, and I got an email from a friend. He said, There's an old 
saying: control a man's purse, and you control half the man. Control a 
man's health, and you control all the man.
  We are talking about a massive change in the lives of every human 
being in America today. That massive change is because we've already 
turned over to the Federal Government most of our financial system for 
them to manage it, so they control our purse. This government controls 
the purse of America, and we have done that this year. It's there. We 
bailed people out. We are now voting members of financial organizations 
and businesses, like automobile firms. Now we want to control the 
American people's purse.
  Now we have to ask ourselves: Well, what's going to happen when we 
do? When we create this great system, how do we know what it's going to 
look like?
  Maybe there's a lot of talk here. I think we've got a fairly 
independent vision. I want to use this vision, quite frankly, but it's 
not fair because it's one-sided, and this document is two-sided, but 
this document printed in smaller font is two-sided. So here is what we 
have in the way of what the government needs to create for a health 
care plan.
  These are government ideas.
  This is the substitute: the people's ideas.
  It's the difference, ladies and gentlemen, between liberty and 
government. You know, this week, a whole lot of people came an awful 
long way so that they could express their opinions, and they were 
called radicals.
  Vote against this bill.
  Mr. RANGEL. Mr. Speaker, I yield 90 seconds to a true expert on our 
country's law system and tax system, the gentleman from Massachusetts 
(Mr. Neal).
  Mr. NEAL of Massachusetts. Thank you, Chairman Rangel.
  Mr. Speaker, let me stand in support of this health care bill today. 
Reforming this health care system has not been easy, but we come here 
today after deliberating for countless years, weeks, months--and as 
recently as this morning more hours added--because we are building a 
baseline of health care for the American family.
  We've worked hard to reform this health care system because, if we do 
nothing, family premiums will increase $1,800 a year; and by 2020, 61 
million Americans will be uninsured. We have analyzed, and we have 
debated the details of the bill line by line and section by section.
  To the critics, yes, we've read the bill.
  For all of the misinformation that has surrounded this legislation, 
there is a great deal that we all here today agree upon: this bill ends 
discrimination based on preexisting medical conditions; it limits out-
of-pocket expenses for families; it bans lifetime limits on health care 
coverage that a family with a critically ill child can bump up against 
in no time at all.
  Limiting out-of-pocket expenses is something we do all agree on. Half 
the bankruptcies in America are health care-related. This bill removes 
the uncertainties of our health care system for families and for 
businesses, for young adults who are no longer eligible for their 
parents' insurance coverage, and for senior citizens in the Medicare 
part D doughnut hole. This is a solid piece of legislation.
  As I close, remember the party that stood with Social Security, and 
remember the party that stood with Medicare as we proceed to this vote 
this evening.
  Mr. CAMP. Mr. Speaker, I yield 3 minutes to the distinguished 
minority leader, the gentleman from Ohio (Mr. Boehner).
  Mr. BOEHNER. I thank my colleague for yielding.
  Mr. Speaker, one of the issues in the underlying bill allows for the 
taxpayer funding of abortion, and the leadership of the majority party 
did see fit to allow Mr. Stupak of Michigan and others to offer an 
amendment that would restore what has been a 30-year effort, that no 
taxpayer funds should be used for abortion.
  If that amendment were to pass, Mr. Rangel, and when this bill comes 
back from committee and if the House does, in fact, pass the Stupak 
language of outlawing taxpayer funding for abortion, will you guarantee 
me, when it comes back, it will be in the bill?
  I would be happy to yield.
  Mr. RANGEL. Mr. Leader, you've been here long enough to truly 
understand how this system works.
  As soon as we pass this bill, then we would expect the Democratic-
controlled Senate to pass their bill. Then we will go into conference, 
and we will work the will of the majority in the House.
  We had no idea that you would expect that a Member, especially one 
that you spoke in such glowing terms of as you have about me--that you 
would expect me on this floor, in front of all of my friends and 
colleagues, to guarantee you anything. I think any Member who gives a 
guarantee might be in violation of our ethics laws, so I wish you would 
kind of take a look at this before you would ask these questions.
  Mr. BOEHNER. In reclaiming my time, Mr. Rangel, if the House does, in 
fact, vote for the Stupak language, in conference, do I have your 
guarantee that your vote will be in favor of the Stupak language?

[[Page 27457]]


  Mr. RANGEL. Well, I haven't normally cut any deals with you as a 
Republican, but why don't you talk to someone on your level in the 
House leadership as you have in the past?
  Mr. BOEHNER. Reclaiming my time, Mr. Speaker.
  Mr. RANGEL. You asked me a question.
  Mr. BOEHNER. This is exactly the point I've been trying to make.
  While the House is expected to take up the Stupak language later on 
this evening, language which would outlaw the taxpayer funding of 
abortion, it's pretty clear that this could be a shell game that's 
underway, that it gets to pass here in the House, helping to ensure 
that this bill passes; but we have no guarantees that when it comes 
back from conference that that language stopping the taxpayer funding 
of abortion will be in the bill.

                              {time}  1645

  Mr. RANGEL. All I am asking, as long as you have been here, have you 
ever had any Member--
  Mr. CAMP. Regular order, Mr. Speaker. Regular order. No time has been 
yielded.
  The SPEAKER pro tempore. The Chair recognizes the gentleman from New 
York.
  Mr. RANGEL. Have you ever gotten a guarantee like that from anybody 
since you have been here? No.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Members will please direct their remarks to 
the Chair.
  Mr. RANGEL. Mr. Speaker, it is my pleasure to yield 1\1/2\ minutes to 
Mr. Thompson of California. I thank him for the great contribution he 
has made to this bill that we present.
  Mr. THOMPSON of California. Thank you, Mr. Chairman, for yielding.
  Mr. Speaker and Members, for far too long too many Americans have not 
had access to quality, affordable health care. Because of this 
legislation, the millions of Americans who don't have health care or 
who are struggling to pay their health care bills will be able to get 
the care they need when they need it. Families, small businesses, and 
individuals will save money.
  There will be no copays or deductibles for preventive care services. 
If you change jobs, you can take your coverage with you. You will not 
be denied coverage for preexisting conditions and families won't be 
bankrupted by high medical bills.
  The bill will also help inject competition into the marketplace to 
help bring down the rising costs of health care insurance. The Medicare 
doughnut hole will be closed and the bill reduces the deficit by at 
least $30 billion over the next 10 years.
  There is still a lot more work to be done, and we are going to fix 
the doctor reimbursement to ensure the best access for our seniors in 
regard to getting health care. Today is a historic day for all 
Americans. It moves us one step closer to quality, affordable health 
care for all Americans.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentleman from Ohio (Mr. Tiberi).
  Mr. TIBERI. Mr. Speaker, the American people do not want their health 
care replaced by government-run health care.
  This bill is flawed in many ways. It cuts benefits to seniors. It 
increases taxes. It's the largest expansion of Medicaid ever at a time 
when State governments across our land are cutting services. It creates 
and extends 43 entitlement programs and 111 new offices, bureaus, 
commissions.
  The Ohio State Medical Association that represents doctors in my 
district is opposed to the bill. They write, ``Medicaid eligibility 
expansion is a troubling trend for the physician community as payment 
for these services often fails to cover the cost of providing care.''
  They go on to say, the legislation ``lacks many of the critical 
elements necessary for successfully reforming Americans' health care 
delivery system and strengthening the physician-patient relationship.''
  The bill does not address medical liability reform, which causes 
defensive medicine to be practiced. Medicare is cut by over $500 
billion. Five million seniors could lose the coverage they have today. 
It turns out that you can't keep what you have if you like it. In fact, 
one of three seniors in my district could lose the benefits they enjoy 
today.
  I am also concerned about the negative impacts on small businesses 
and employers. Under the ``pay or play'' mandate in this bill, Mr. 
Speaker, $135 billion in new taxes will be thrust upon those 
businesses. This could cause over 5.5 million Americans to lose their 
jobs.
  Mr. Speaker, we have a better way, a better alternative that will 
lower health care premiums, guarantee health care to affordable health 
care for those with preexisting conditions, allow States flexibility to 
provide more coverage, and protect the benefits of our seniors.
  Americans deserve better, Mr. Speaker. There is a better way. Let's 
reject this bill and start over.
  Mr. RANGEL. Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman 
from Nevada (Ms. Berkley) and thank her publicly for the great 
contribution she has made to this bill.
  Ms. BERKLEY. I thank the chairman for his kind words and his 
leadership on this issue.
  Mr. Speaker, I rise today in support of this historic piece of 
legislation that will expand health care coverage to millions of my 
fellow Americans.
  The way we provide health care in this country is unsustainable. In 
Nevada, the cost of a private family health insurance plan is expected 
to grow from over $11,000 in 2009 to more than $19,000 10 years from 
now. If we do nothing, we will reach a point in this country where 
hardly anyone will be able to afford health insurance.
  This bill is good for Nevada. Over 400,000 uninsured Nevadans will be 
able to get health insurance because of this bill. This bill is good 
for Nevada's seniors. It closes the doughnut hole, eliminates copays 
for preventive services and extends the life of Medicare over 5 years.
  The bill isn't perfect. It doesn't contain a provision to protect 
bone density tests that I fought for, and it doesn't fix the Medicare 
physician payment system, and we must do both. But I support this bill 
today for the needed reforms that are included. They are very 
important. It's a great first step.
  Faye Schwartzer in Las Vegas, Nevada, this vote is for you.
  Mr. CAMP. At this time I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentlewoman from Florida (Ms. Ginny 
Brown-Waite).
  Ms. GINNY BROWN-WAITE of Florida. I thank the gentleman.
  Mr. Speaker, the bill before us creates 111 different offices, 
bureaus, commissions, programs and entitlements, but it only cuts one--
Medicare. This bill steals more than $500 billion from our Nation's 
seniors to fund new entitlement programs for the young, the healthy and 
the wealthy.
  My colleagues in the majority have boldly decided that cutting $500 
billion from Medicare is a good idea. They actually are telling seniors 
that these cuts will improve Medicare in the future.
  Well, Grandpa and Grandma might be old, but they are not stupid. You 
are not going to cut Medicare and tell them that it's a good thing.
  The bottom line is that this bill is not real reform. Congress should 
be strengthening Medicare, not weakening the program. Just look at how 
bad the Federal Government has been historically in predicting health 
care costs. This bill will increase health care costs for all Americans 
and cut Medicare funding. Americans don't believe that yet another 
trillion-dollar program will cost them nothing.
  Mr. Speaker, we all hear Speaker Pelosi say that she is a mother and 
a grandmother. Like Speaker Pelosi, I too am a mother and a 
grandmother. I can tell you that my constituents believe that this bill 
is bad for the middle class, bad for parents and grandparents and, even 
worse, for future generations.
  I cannot support this bill. I urge my colleagues to reject it as well 
so that we can work together truly on a bipartisan solution. The 
President's own

[[Page 27458]]

economic advisors have said that this bill will kill 5.5 million jobs. 
Americans back home are watching this and saying, What is Congress 
thinking? Why would they want to further sabotage our economy? This 
bill clearly is not what America wants. They want an incremental 
approach. Nobody is defending health care as we know it. We are saying, 
let's fix what's broken.
  I urge my colleagues to vote against this bill. It is dangerous for 
our economy. It is not something that every American needs, wants or 
can afford at this time.
  Mr. RANGEL. I yield 1\1/2\ minutes to the gentlewoman from 
Pennsylvania (Ms. Schwartz) and I would like to publicly thank her for 
the many hours that she put in on H.R. 3200.
  Ms. SCHWARTZ. Thank you, Mr. Chairman.
  Finding a uniquely American solution to ensure that all Americans 
have access to meaningful, affordable health coverage has been an 
unfulfilled goal for decades.
  Today we have the opportunity to make this moral and economic 
imperative a reality. I want to acknowledge the extraordinary 
leadership of our chairman and of the cooperation of three committees 
in the House and all of the Members who were so engaged in developing 
the bill before us today.
  The Affordable Health Care for America Act meets the goals of health 
care reform: enhanced consumer protection for those with health 
coverage, eliminating preexisting condition exclusions; new, affordable 
choices for individuals and small business; strengthened Medicare for 
our seniors with better prescription drug coverage and greater access 
to primary care; improved delivery of care with better health outcomes 
for all Americans; and the containment of rapidly rising costs of 
health care.
  It builds on America's public-private system and is paid for, now and 
into the future. The status quo is unaffordable, unsustainable and 
unacceptable.
  Now is the time to act on behalf of the millions of Americans without 
insurance and the millions more who are underinsured, on behalf of 
small and large businesses who struggle every day to pay the rising 
cost of insurance for their employees, on behalf of seniors. In fact, 
on behalf of all Americans who worry about our families getting the 
health care they need and then being able to pay for it, today is a 
great day for America.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentleman from Kentucky (Mr. Davis).
  Mr. DAVIS of Kentucky. Mr. Speaker, we all agree we need to improve 
health care quality and increase access, but this bill fails to do so. 
Republicans know health care reform can be accomplished without raising 
taxes for families and small businesses, without increasing the size of 
government, without cutting Medicare benefits.
  This week, tens of thousands of Americans traveled to Washington, 
D.C., to demand a health bill that would increase access, reduce cost, 
save jobs and keep the government out of our health decisions.
  Instead of listening, Democrats squelched over 45 health care bills 
in favor of a tyrannical bill that cuts senior benefits, creates 118 
new agencies, boards and programs, kills jobs and raises taxes by $730 
billion.
  Unemployment has reached a staggering 26-year high and Speaker 
Pelosi's health care bill will cost another 5.5 million jobs. Americans 
don't want reform that comes with higher cost and unemployment.
  This is a misguided effort by the majority, making it more 
complicated and expensive to create jobs. The Northern Kentucky Medical 
Society and thousands of doctors nationwide are opposed to this bill, 
H.R. 3962. They know that government takeover of health care will put 
bureaucrats between doctors and patients.
  We can craft responsible health care legislation, and that's exactly 
what my Republican colleagues have done in H.R. 4038, the Common Sense 
Health Care Reform and Affordability Act. Our substitute reduces 
premium costs for every American to make health insurance more 
affordable and accessible, without raising taxes and without cutting 
Medicare benefits on our seniors.
  Under our bill, insurance premiums are $5,000 cheaper per family than 
the cheapest Democratic bill. This bill takes waste and costs out of 
the system instead of adding to it. The Republican bill heeds the pleas 
of the people without spending $1.3 trillion, without killing jobs and 
without hurting seniors.
  Madam Speaker, H.R. 3962 is not reform; it is tyranny. Give the 
people health reform, health freedom, and kill this bill.
  Mr. RANGEL. Mr. Speaker, I yield 1\1/2\ minutes to my friend and 
leader from the great State of New York (Mr. Crowley).
  Mr. CROWLEY. I thank my good friend, the gentleman from New York, for 
yielding me this time.
  I rise today in support of the Affordable Health Care for America 
Act, which will provide millions of hardworking American families the 
quality, affordable health care they deserve. In the past decade, the 
cost of health care for American families has skyrocketed. Premiums 
have doubled, yet wages remain stagnant at best.
  Last year, more than half of Americans postponed care or skipped 
their medications because they simply could not afford them. The status 
quo is no longer acceptable nor affordable, and the status quo is 
changing today. Today Democrats are taking action and delivering to the 
American people real change, a better, safer, more affordable way of 
life.
  The Affordable Health Care for America Act will give American 
families peace of mind, peace of mind that health care is not just a 
luxury for some but an affordable, accessible benefit for all of us.
  I urge all of my colleagues to make history today and vote ``yes'' on 
this bill to make health insurance affordable and accessible for each 
and every American.

                              {time}  1700

  Mr. CAMP. Mr. Speaker, at this time I yield 2 minutes to a 
distinguished member of the Ways and Means Committee, the gentleman 
from Washington State (Mr. Reichert).
  Mr. REICHERT. I thank the gentleman for yielding.
  Mr. Speaker, we have heard yesterday's announcement: unemployment 
eclipses 10 percent. Yet today we are considering a health care bill 
that will cost even more jobs and will raise taxes on families, on 
small businesses, on seniors, and takes away freedom.
  This bill especially hurts our seniors, our greatest generation, by 
cutting their benefits, raising their premiums, and, on top of that, 
taxing wheelchairs, taxing pacemakers, taxing hearing aids.
  This bill is not right for America, it is not right for families, it 
is not right for small businesses, and it is not right for seniors. We 
need real solutions.
  Let's focus on reducing the costs maybe, offer tax incentives, enact 
medical liability reform, allow people to buy insurance across State 
lines. These solutions bring lower costs and bring health care to those 
who really need it.
  Mr. Speaker, the most troubling aspect, though, of this bill is that 
it takes away freedom, and this freedom came through great sacrifice, 
the sacrifice of men and women throughout the history of this great 
Nation so that we could choose and live a free life. This bill takes 
away that freedom, the freedom to choose the health care that is right 
for you and your family. This bill takes away that freedom, requiring 
every American to purchase a government-approved health plan, pay a 
tax, or even go to jail. This bill takes away the freedom of patients 
to consult with their doctors without government interference. And this 
bill takes away that freedom, the freedom of our seniors to choose 
their own health care plan.
  So, Mr. Speaker, this is not only a job-killing bill. Mr. Speaker, 
sad to say, this is a freedom-killing bill.
  Mr. RANGEL. Mr. Speaker, I yield 90 seconds to the gentleman from New 
Jersey (Mr. Pascrell), and thank him for the great job he has done for 
the committee.

[[Page 27459]]


  Mr. PASCRELL. Mr. Speaker, no one believes the loyal opposition that 
Democrats don't care about seniors. Need I provide a history lesson 101 
here?
  Today is when we must ask ourselves the real reason we came to 
Congress. Was it to fulfill the hopes of the people, or to take the 
path of least resistance? The easy thing would be to say the problem is 
too big, the interests are too aligned, and then maintain the status 
quo. The hard thing is to bring everybody together, make the 
compromises that need to be made, and give the American people true 
health care reform that will carry our country through for generations.
  This is the same choice that was laid before the Members of the 89th 
Congress when they voted on the creation of Medicare and Medicaid. And 
where would we be today as a nation had those Members simply succumbed 
to the difficulty of making real change? Where would we be today? Where 
would we be in mortality? Where would we be with the seniors who were 
sick and poor at that time without those two programs?
  We are now 40th among the industrial nations in infant mortality. 
When will we wait to have our consensus? We need this reform. Let us 
not leave another generation to wonder what we could have been.
  Let's pass historic legislation that provides the promise of 
affordable health care for every American today and the generations to 
come.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of 
the Ways and Means Committee, the gentleman from Louisiana (Dr. 
Boustany).
  Mr. BOUSTANY. Mr. Speaker, today we will have a vote on a flawed, 
massive, and irresponsible health care takeover by government, pushed 
by Speaker Pelosi and House Democrats, that will cost more than $1 
trillion. This bill will increase health care costs for most Americans, 
increase taxes while Americans struggle to find work, and hurt seniors' 
quality care.
  Mr. Speaker, as a heart surgeon, I saw the amazing innovation in my 
20 years in practice in our system. In fact, in the early 1950s, an 
American surgeon, hopelessly observing the death of a patient from 
blood clots to the lungs, was inspired and invented the first heart-
lung machine that made open heart surgery possible. Many thousands of 
patients worldwide have benefited from this innovation, this innovation 
right here in the United States, innovation that will be stifled by the 
Pelosi health care bill.
  There is another way. We can do better. House Republicans have 
solutions that will lower costs by creating real choice and 
competition. We will help those with preexisting conditions to get 
meaningful health care coverage, we will preserve U.S. leadership in 
medical innovation and education, and we will reduce frivolous lawsuits 
in medicine that needlessly drive up the costs for families.
  As a heart surgeon, I know that we can achieve real health care 
reforms to bring down costs. But the Democrats' current bill will only 
lead to higher costs for millions of Americans and destroy what is 
currently working in our system.
  There is a better way. There is a different way. There is a way to 
lower health care costs, help more people achieve a high quality 
doctor-patient relationship in this country and improve health care for 
all Americans.
  Vote down this bill and support the Republican plan.
  Mr. RANGEL. Mr. Speaker, I now yield 1\1/2\ minutes to the gentleman 
from Illinois (Mr. Davis).
  Mr. DAVIS of Illinois. Mr. Speaker, passage of this bill will move us 
closer to the realization that all men, women, and children in this 
country can have access to quality health care. It will reduce the 
waiting time in emergency rooms and shorten the length of time you have 
to wait to see a doctor. It makes it possible for people to have health 
insurance who have never had any before in their lifetime and to see a 
doctor on a regular basis. It recognizes the needs of people with 
disabilities. It seriously increases the number of community health 
centers, protects disproportionate share and teaching hospitals, and 
promotes health awareness and education. But, most importantly, it 
prolongs and enhances life, as well as its quality.
  This is the most significant health legislation passed in this 
country since Medicare and Medicaid. Residents of my district have been 
calling all day asking that I would vote for them, that I would vote 
for Illinois, that I would vote for America. I tell them, yes, I will, 
because I believe that health care ought to be a right and not a 
privilege.
  I wanted a single-payer system, but I will vote for H.R. 3962 because 
it is good for Illinois, it is good for me, it is good for you, and it 
is good for America.
  Mr. CAMP. Mr. Speaker, I yield 2 minutes to the distinguished member 
of the Ways and Means Committee, the gentleman from Nevada (Mr. 
Heller).
  Mr. HELLER. Mr. Speaker, I thank the ranking member for his 
exceptional hard work in producing a Republican alternative that does 
not raise taxes, raise premiums, increase our debt or increase health 
care costs.
  In a recent article, the Democratic leadership stated that getting 
votes today will be easier because Democrats want to go home.
  Mr. Speaker, the Pelosi health care bill will cost Americans more 
than 5 million jobs. Despite national unemployment at 10.3 percent, and 
in my home State of Nevada, over 13 percent unemployment, we are moving 
forward with this bill. For the majority, this is fine, if Members of 
Congress get to go home.
  This legislation raises billions in new taxes on small businesses and 
increases health care premiums by $15,000 per family on average. But, 
as I said, as long as the majority gets to go home, this doesn't 
matter.
  This bill cuts $500 billion from Medicare, affecting more than 20,000 
seniors in my district and over 100,000 Statewide, and also avoids 
meaningful medical liability reform. But the majority will support it, 
because they get to go home.
  This bill's individual mandates will result in 9 million Americans 
paying a new tax or facing criminal penalties. These penalties include 
$250,000 fines and/or 5 years in jail for failure to pay the tax. 
However, this doesn't matter, as long as the majority gets to go home 
today.
  Mr. Speaker, this bill lacks enforceable citizenship verification 
provisions. As many as 8.5 million illegal immigrants will be eligible 
for taxpayer-subsidized health care under this legislation. But, of 
course, if the majority gets to go home, it simply doesn't matter.
  Yet the height of hypocrisy is that Members are not required to 
participate in this government-run health care program.
  Unfortunately, the strategy to pass this massive bill hinges upon 
Members of Congress wanting to go home, instead of passing legislation 
that will help the American people.
  Mr. RANGEL. Mr. Speaker, I yield 90 seconds to a hardworking member 
of the Ways and Means Committee from the sovereign State of New York 
(Mr. Higgins).
  Mr. HIGGINS. Mr. Speaker, the American health care industry is a $2.5 
trillion industry. It represents 17 percent of the American economy, as 
measured by the gross domestic product. Yet our outcomes, according to 
the World Health Organization, are pathetically falling behind. We are 
37th in overall quality. Unacceptable in America. We are 41st in infant 
mortality. That means in 40 other countries, from birth to 1 year of 
age, kids live by a higher percentage than they do in the United 
States. Unacceptable in America. We are dead last of any industrialized 
country in preventable deaths. Unacceptable in a good and generous 
Nation.
  This is a uniquely American problem with a uniquely American 
solution. We look to not-for-profit plans, like the Cleveland Clinic, 
the Mayo Clinic and Johns Hopkins. They are early adapters of new 
innovation, and they are providing the highest quality health care, not 
only in the Nation, but throughout the world, at the lowest

[[Page 27460]]

possible cost. That is the health care that I want for my family, that 
is the health care that I want for my community, and that is the health 
care I want for my Nation.
  We have been debating this issue not for seven months, but for seven 
decades. It is time for change. I understand that reform is tough. The 
reformer, said Machiavelli, has enemies in all those who profit by the 
older order, and only lukewarm defenders in all those who would profit 
in the new order. On health care, most Americans are rooting for the 
reformer.
  Mr. CAMP. Mr. Speaker, at this time I yield 2 minutes to a 
distinguished Member of the Ways and Means Committee, the gentleman 
from Illinois (Mr. Roskam).
  Mr. ROSKAM. I thank the gentleman for yielding.
  Mr. Speaker, if you are at home and you are sort of flipping channels 
between the football games and C-SPAN, and you flipped on and only 
heard the majority party, you would think, wow, what a great plan. I 
mean, really, you would think people are just going to fall all over 
themselves, and all these adjectives and declarative statements just 
sound wonderful. Until you look inside that bill and you find 
handcuffs.
  Now, I am not talking about figurative handcuffs. I am talking about 
criminal penalties; criminal penalties that have been mentioned by the 
gentleman from Texas, criminal penalties that have been mentioned time 
and again on this floor. We have heard from the best and the brightest 
all afternoon, and not a one of them have answered why it is you have 
to criminalize people to coax them into a plan that is fabulous. It 
makes no sense.
  And these aren't my words. This is actually coming from the Joint 
Committee on Taxation, in a letter that was written, ironically, with 
Chairman Charlie Rangel as the chairman of that committee, released 48 
hours ago, that says in fact if you don't comply with the individual 
mandate, what happens to you? You can be subject to 5 years in prison 
and you can be subject to a quarter of a million dollars in fines.

                              {time}  1715

  And the other side, with all due respect, with all the adjectives and 
all the flourishing speech, has failed to answer that question.
  I submit to you, if we listen today, if we listen to the remainder of 
this debate, they will be silent in terms of a good answer as to why it 
is you need to criminalize people to coax them into a plan. It's a 
failure, and we ought not stand for it.
  The small businesses, the entrepreneurs, and the self-employed that 
this would have an impact on, they say, ``Look, don't criminalize us. 
Give us relief. Let us purchase across State lines.'' Not in the 
Democrats' bill. ``Give us real tort reform, real liability reform.'' 
Not in the Democrat bill in any substantive way. ``Let us purchase and 
work together to pool to lower costs down.'' The right to remain silent 
shouldn't be the word from the government.
  Mr. RANGEL. At this time, I yield 90 seconds to the gentleman from 
Kentucky (Mr. Yarmuth).
  Mr. YARMUTH. Mr. Speaker, 3 years ago today, the citizens of 
Louisville, Kentucky, sent me to this body. They sent me here largely 
to help bring us to this moment.
  I was sent by a recent college graduate who had to give up her 
coverage under her parents' health insurance policy and couldn't get 
her own coverage to cover her lifelong allergic condition.
  I was sent by the family of a 10-year-old little boy who wrote me, 
begging for help to help pay for the $50,000 they have to pay annually 
to care for their autistic brother.
  I was sent by the Louisville woman whose insurance was dropped in the 
middle of her cancer treatment.
  I was sent by thousands of seniors, struggling to pay their 
prescription drug costs.
  I was sent by people like the local realtor who is trying to figure 
out right now how to pay his next year's insurance bill he just 
received with a 32 percent increase.
  Today is the day those Americans get the help they have been praying 
for. It is the day we take a giant step toward that more perfect Union 
that we all seek. I am very proud to be a part of this historic day, 
and I am also very proud for the all-too-patient citizens of America 
who sent me here, along with many of my colleagues, in 2006 to cast 
votes for the Affordable Health Care for Americans Act.
  Mr. CAMP. Mr. Speaker, at this time, I yield 1 minute to the 
gentlewoman from Michigan (Mrs. Miller).
  Mrs. MILLER of Michigan. Mr. Speaker, during the past year, the 
Democratic majority has passed so many bills that have done absolutely 
nothing to help our economy. Instead, they've raised taxes, they've 
exploded the deficit, and they actually have killed off jobs. Then, 
yesterday, the national unemployment rate went up past 10 percent--
actually, to 10.2 percent, with no end in sight.
  So it is incredible that today this House may pass a job-killing, 
tax-hiking, deficit-exploding government takeover of our health care. 
And one of the most disingenuous things that has been said is that if 
you like your current health care, that you can keep it. Well, not so 
fast.
  In my county, Macomb County, Michigan, the Chamber of Commerce just 
did a survey of all of their members. They asked them that if, rather 
than continuing to provide good health care plans for their employees, 
they would instead take the 8 percent penalty that is included in this 
bill, and guess what? No surprise. The overwhelming majority said they 
would of course dump their employees out into the public plan.
  Mr. Speaker, we are going to have a complete government takeover of 
our health care system faster than you can say, ``This is making me 
sick.'' Vote ``no.''
  The SPEAKER pro tempore (Mr. Jackson of Illinois). The gentleman from 
Michigan has 8 minutes remaining. The gentleman from New York has 14\1/
2\ minutes remaining.
  Mr. RANGEL. Mr. Speaker, I would like to yield 1 minute to the 
Congresswoman from California (Ms. Lee), who is the chairperson of the 
Congressional Black Caucus and has done such a great job on the 
question of diversity as well as other parts of the bill for women.
  Ms. LEE of California. Mr. Speaker, on behalf of the Congressional 
Black Caucus, I rise in strong support of this bill. Known historically 
as the conscience of the Congress, we recognize that it is our moral 
responsibility to pass this today.
  I want to thank the gentleman and commend him and the other Chairs of 
the tri-committees as well as our leadership and our Speaker for 
bringing us to this point today.
  The strong public option in this bill will provide our constituents 
with the choice and competition they want. It will help improve health 
equity and help eliminate health disparities, and this bill recognizes 
that an ounce of prevention is worth a pound of cure. It will help 
people who choose to keep their private plans by limiting annual rate 
increases by insurance companies.
  Today's historic vote is another step forward in our quest for social 
justice. It really is about life and death, but it's not the end of the 
process. The Congressional Black Caucus will keep fighting until a 
final bill is on the President's desk.
  Today, finally, health care will become a basic human right for all, 
rather than a privilege for the few. We all have been called today for 
such as this. Let us rise to the occasion and vote ``yes'' on 
affordable health care for all.
  Mr. CAMP. At this time, Mr. Speaker, I yield 1 minute to the 
gentlewoman from Oklahoma (Ms. Fallin).
  Ms. FALLIN. Mr. Speaker, the American people understand the need for 
health care reform. They just don't want socialized medicine. They 
don't want the Federal Government taking over our health care 
decisions, taking away our freedoms of choice about health care. They 
don't want more Federal deficit spending on the backs of our children 
and future generations of our children, and they don't want

[[Page 27461]]

more taxes upon small business, especially in this recession.
  They don't like the Federal Government taking away our freedoms 
guaranteed under this Constitution, and they don't want the Federal 
Government interfering in our States' rights. They don't want unfunded 
mandates upon the States, and they don't want government-funded 
taxpayer abortions upon our families.
  Mr. Speaker, men and women have fought for our freedoms for this 
Nation for generations, but this health care bill will change the face 
of our Nation and put our Nation on a trajectory of a Federal 
Government takeover in so many areas of our freedoms and our lives.
  Let's reject this health care bill, and let's start all over and pass 
real, meaningful health care reform.
  Mr. RANGEL. I yield 1 minute to the gentlewoman from New York, 
Congresswoman Velzquez.
  Ms. VELAZQUEZ. For too long, millions of Americans have suffered 
without access to the medical treatment they need. Right now, as we 
debate this measure, too many Americans are worrying about how they 
will find health care coverage if they lose their jobs. On this day 
alone, 14,000 Americans will lose their coverage, and millions of other 
citizens, including one in every three Hispanics, lack health insurance 
coverage.
  Today all of that changes. This is the moment. No longer will 
insurance companies abandon Americans when they most need help. This 
bill will end the practice of denying Americans coverage because of 
preexisting conditions. The 36 million uninsured Americans will finally 
have coverage. Choice, competition, and transparency will be brought to 
the insurance market, meaning better care at lowered costs.
  I say this to my colleagues: It has been too long. Let us pass this 
bill.
  Mr. CAMP. Mr. Speaker, I yield 1 minute to the gentleman from Florida 
(Mr. Crenshaw).
  Mr. CRENSHAW. Mr. Speaker, a lot of the men and women that I 
represent in northeast Florida are members of the military, and we've 
been working for 15 years to make sure they have adequate health care. 
They deserve it. They defend us every day.
  They asked me, How is this new Democratic plan going to affect my 
TRICARE and my TRICARE for life? The answer is nobody really knows what 
this slippery slope with the public option is going to do to existing 
coverage. If you take this Democratic plan, you will see it's 
complicated, 2,000 pages long. It's unproven. It's untested. It's 
filled with uncertainty.
  At the end of the day, this Democratic plan is a dangerous experiment 
on the backs of the American people without their consent. If this were 
the medical field, that would be unethical. It would be malpractice. 
There is a better way, Mr. Speaker. There is a better way.
  Mr. RANGEL. I yield 1 minute to the gentlewoman from Michigan, 
Congresswoman Kilpatrick.
  Ms. KILPATRICK of Michigan. I thank the gentleman for yielding.
  Mr. Speaker, this is a historic day. Choice, competition, quality, 
and peace of mind. I want to commend the Speaker for her leadership and 
our chairman in our caucus for putting together a bill that will help 
American families.
  The 36 million Americans who do not now have insurance will be 
insured. Your premium costs will go down. The quality of all insurance 
will be increased. No longer will insurance companies be able to 
examine and cut you off when you get ill. Prescription drugs will be 
cheaper. The AARP supports this bill. Medical doctors and nurses 
support this bill. The Consumers Union supports this bill. The UAW 
supports this bill.
  It's a great historical day for our country. I predict it will be, as 
we go forward, as strong and as popular as Social Security, Medicare, 
and now our new national health care program.
  Thank you. Thank you, Madam Speaker. Thank you, Democrats, for 
standing strong.
  Mr. CAMP. Mr. Speaker, at this time, I yield 1 minute to the 
gentlewoman from West Virginia (Mrs. Capito).
  Mrs. CAPITO. Mr. Speaker, I rise today to voice the concerns of my 
constituents who believe the Speaker's trillion-dollar 1,990-page bill 
is simply the wrong solution for West Virginia's families. We were told 
that under the President's plans, those who like their health care 
would be able to keep it. Well, we now know that is simply not true. It 
is certainly not true for the 72,000 West Virginians on Medicare 
Advantage who will see the program slashed by $170 billion under this 
plan.
  Consider one of my elderly constituents from Dunbar, West Virginia, 
who called just today. She relies on the enhanced benefits of Medicare 
Advantage to cover her rheumatoid arthritis and her diabetes. She 
suffered a stroke, a brain aneurysm, and she is on more than a dozen 
prescriptions. She relies on these services, and she fears that this 
bill will put them at risk. Sadly, she is right, because this bill will 
change her health care.
  Mr. Speaker, we need health care reform, but we can do better than 
this.
  The SPEAKER pro tempore. The gentleman from Michigan has 5 minutes 
remaining. The gentleman from New York has 11\1/2\ minutes remaining.
  Mr. RANGEL. Thank you. I yield 1 minute of that to the gentleman from 
the great State of New York, Gregory Meeks. 
  Mr. MEEKS of New York. The camera of history is rolling, and I am so 
happy to play a part in it, because just as we created history in the 
thirties with Social Security and in the sixties with Medicare, we will 
create history tonight in passing H.R. 3962.
  Dr. King once asked the question, How long? Well, because of H.R. 
3962, how long before all Americans have access to affordable and 
quality health care? Not long. How long before we end discrimination 
for preexisting conditions? Not long. How long before we ensure that no 
Americans fear bankruptcy or financial ruin due to illness? Not long. 
How long before we close the doughnut hole, helping all of our senior 
citizens? Not long. How long before we begin to control the escalating 
prices of insurance and health care? Not long. How long before all 
Americans, all of us, can have access to quality health care? Not long.
  Mr. CAMP. At this time, Mr. Speaker, I yield 1 minute to the 
gentleman from Virginia (Mr. Goodlatte).
  Mr. GOODLATTE. Mr. Speaker, what's in this 2,000-page monstrosity 
that's costing the taxpayers over $1 trillion in costs? Well, we're 
going to see tax increases of $800 billion, and $500 billion in cuts 
from Medicare.
  Well, take a look on page 94. Section 202(c) prohibits the sale of 
private health insurance policies beginning in 2013, forcing 
individuals to purchase coverage through the Federal Government.
  On page 225, however, section 330 permits, but does not require, 
Members of Congress to enroll in government-run health care.
  Page 122, section 233(a)(3) requires the commissioner, a new health 
insurance czar, to issue guidance on best practices of plain language 
writing. This from the same people who wrote this 2,000-page health 
care bill.
  Page 183, section 305(a) gives the commissioner the power to enlist 
appropriate entities, like Planned Parenthood and ACORN, to engage in 
outreach to specific vulnerable populations about the bill's new 
programs.
  Oppose this bill.
  Mr. RANGEL. Mr. Speaker, at this time, I yield 1 minute to 
Congressman Conyers, the distinguished dean of the Congressional Black 
Caucus, senior Member of this great House of Representatives, and 
someone that had indicated his concern about health care from many, 
many years ago.

                              {time}  1730

  Mr. CONYERS. Thank you, Chairman Rangel, and all of our colleagues 
that have supported single-payer health care. Eighty-six other Members 
are now working to make sure that we get this bill passed. I single out 
my colleagues Dennis Kucinich and Anthony Weiner for their particularly 
effective work.
  But I want to say that this is the same battle that some people went 
through when we passed Social Security. We had the same naysayers. The

[[Page 27462]]

same people when we passed Medicare, the same naysayers. The same 
people when we passed Medicaid, the same naysayers. And now we try to 
reform health care today, and what do we get? The same people saying 
``no'' again.
  So I'm proud to bring all of the support that I can to make sure that 
this bill becomes law, that more people are covered, and that 
preexisting conditions no longer will be an excuse to get rid of 
people.
  Mr. CAMP. Madam Speaker, at this time I yield 1 minute to the 
gentleman from Georgia (Mr. Kingston).
  Mr. KINGSTON. I thank the gentleman for yielding.
  Madam Speaker, what we have today is another Pelosi plan for America.
  But let's remember the Pelosi plan for jobs: an $800 billion stimulus 
plan that caused unemployment to go from 8.5 percent to over 10 
percent.
  Let's remember the Pelosi plan for automobiles: Cash for Clunkers, a 
$3 billion program that even the Democrats agreed did not work and was 
killed after 3 weeks.
  The Pelosi plan for fiscal discipline: a $1.4 trillion debt this 
year, the highest in history.
  And let's don't forget the Pelosi plan for national security: 
dithering in Afghanistan.
  Now we have the Pelosi plan for health care: it kills small 
businesses and jobs. It raises taxes. It raises premiums. It cuts 
Medicare. It takes away your current health care coverage and spends $1 
trillion.
  Vote ``no'' on the Pelosi plan for a government takeover of health 
care and join the bipartisan Members of this Congress who plan to 
promote an alternative which is far better.
  Mr. RANGEL. Madam Speaker, I yield for the purpose of making a 
unanimous consent request to Mr. Faleomavaega, my friend from Samoa.
  Mr. FALEOMAVAEGA. Madam Speaker, God is good. I rise in full support 
of the health care needs of all our fellow Americans. God bless 
America.
  Madam Speaker, I rise in strong support of H.R. 3962, legislation to 
provide affordable, quality health care for all Americans and reduce 
the growth in health care spending, and for other purposes. This bill 
will control rising medical costs and also extend health care coverage 
to uninsured American citizens throughout the United States and its 
Territories.
  I want to thank Speaker Nancy Pelosi for her leadership and my 
colleagues in Congress for their support on this important bill. 
Especially, I extend my gratitude to the Chairmen of the House 
Committee on Energy and Commerce, Congressman Henry Waxman; and the 
House Committee on Ways and Means, Congressman Charles Rangel for 
listening to the concerns of the Territories and for their willingness 
to work with the Territorial delegates on resolving their concerns.
  I also want to commend my fellow Territorial delegates for their hard 
work and efforts, in working hand-in-hand to reduce health disparity 
facing the Territories. I especially want to recognize Congresswoman 
Donna Christensen for her work in the House Committee on Energy and 
Commerce, Congressman Pedro Pierluisi and Congressman Gregorio Sablan 
for their advocacy in the House Committee on Education and Labor and to 
Congresswoman Madeleine Bordallo for her leadership as the Chairwoman 
of the Congressional Asian Pacific American Caucus Healthcare Task 
Force.
  Madam Speaker, the Affordable Health Care for America Act, or H.R. 
3962, will improve health care for Americans living in the insular 
areas. Under the provisions of this legislation, from FY2011 through 
FY2019, American Samoa will receive additional Medicaid funding in the 
amount of $239.5 million. Moreover, its Federal Medical Assistance 
Percentage (FMAP) will be raised to the highest FMAP applicable to any 
of the 50 States and District of Columbia. As a result American Samoa 
will assume an FMAP no less than 75 percent, the FMAP for Mississippi 
which has the highest among the 50 States.
  American Samoa will also work together with the Secretary of Health 
and Human Services on a plan to transition the Territory to full parity 
by 2020. And to make this transition, the Secretary will also assist to 
make appropriate modifications to the Territory's existing Medicaid 
programs. This will require comprehensive assessment of the existing 
Medicaid program and health care services in American Samoa.
  I am pleased that American Samoa and the insular areas will have the 
opportunity to become part of the Exchange program, the centerpiece of 
the Health Care Reform legislation. Again I thank my Territorial 
delegates for their hard work to ensure that Congress continues to 
recognize the need and unique set of circumstances we have in the 
Territories. To help carry out the Exchange program, $300 million is to 
be allocated among American Samoa, the CNMI, Guam, and the USVI, based 
on consultation with the Secretary of Health and Human Services. If 
American Samoa or any Territorial government chooses not to join the 
Exchange, its allocation will be added instead to that Territory's 
Medicaid funding.
  Madam Speaker, H.R. 3962 will bring much needed improvement to the 
health care system in American Samoa. The fact of the matter is rising 
medical costs and limited health care coverage, exacerbated by American 
Samoa's remote location and exponential rate of chronic diseases, have 
led to a high number of people in the Territory with minimal or no 
access to quality health services. Indeed, findings from the American 
Samoa Health Survey conducted in 2005 estimated only 25 percent of the 
population have insurance. Subsequently, there is a tremendous need to 
address these concerns in a viable health care policy for the 
Territory.
  For this reason, in a letter sent June 22, 2009, I wrote members of 
the Fono (American Samoa Legislature) to address the need to improve 
the health care system in the Territory. I specifically requested that 
the Fono should take advantage of the report from the Coverage for All 
in American Samoa (CAAS) project, which includes policy recommendations 
on ways to improve the Territory's health care system.
  I commend the American Samoa Government especially the Office of the 
Lieutenant Governor and staff for their dedication and commitment to 
the CAAS project that was completed in 2007. I also want to commend the 
Health Resources and Services Administration (HRSA) of the U.S. 
Department of Health and Human Services (DHHS) for committing total 
funding of $1.2 million from 2004 to 2007 to complete the CAAS project. 
My hope is for the American Samoa Government to follow through on the 
policy recommendations in the CAAS report and adopt the framework for 
health care reform that is now in place and supported by H.R. 3962.
  The Affordable Health Care for America Act, H.R. 3962, carries with 
it our expectations and hopes for quality and affordable health care 
for our people and with it a commitment; a commitment to ensure that 
every American is provided quality health care that they are entitled 
to and to receive health services that they so critically need.
  I urge my friends and colleagues to support H.R. 3962 and pass this 
historical health care reform legislation.
  Mr. RANGEL. I yield myself 2 minutes.
  This is it for the members on the Ways and Means Committee and others 
that have demonstrated such outstanding leadership to be a part of 
history.
  It's unfortunate that we were unable to create an atmosphere of 
bipartisanship because, certainly, the 40 million people that are 
without health insurance, we can't distinguish between those who are 
Republicans and those who are Democrats. Clearly, we had enough 
information of the number of people that were in the congressional 
district, all of our congressional districts, that had no insurance at 
all.
  I am more than certain that my colleagues on the other side of the 
aisle have heard the very same stories we have: people who thought they 
were insured and they were not; people who wanted insurance and they 
would not insure them because they had some condition; other people who 
worked hard every day of their lives, but were not given insurance and 
they can't afford to buy it.
  No, this isn't the Pelosi plan. This is a plan for all America, a 
plan to make us proud to know that our country is concerned about us 
and our children and our grandchildren. And, yes, the American Medical 
Association, AARP, and everyone is throwing papers around. But these 
are the groups, the national groups, that have asked America and this 
Congress to step up and fulfill our responsibility.
  And it's not just for our constituents. It's for our great country, 
to have her as strong as she can be, to be able to know that we can 
compete with any other nation no matter what part of the world that 
we're in; and that our

[[Page 27463]]

workforce will not only be educated and talented in order to compete, 
but we will be healthy.
  Every industrialized country takes care of their people. It's not a 
political thing. Certainly here it's not a Republican or Democratic 
thing. It's, Are we going to be healthy? Are we going to be strong? Are 
we going to be certain that when you count America, count her among the 
healthy.
  Madam Speaker, I want to bring to the floor an outstanding Member of 
Congress who is the subcommittee Chair on the Education and Labor 
Committee. As you know, three committees had jurisdiction and Education 
and Labor had jurisdiction. We had three chairmen. But we had one 
subcommittee chairman who has just been outstanding. He's been a friend 
of those without insurance, a friend of those who look forward to this 
bill's being passed.
  So it is with great distinction that I yield the balance of my time 
to Mr. Robert Andrews from New Jersey, and I ask unanimous consent that 
he be allowed to control that time.
  The SPEAKER pro tempore (Ms. Edwards of Maryland). Without objection, 
the gentleman from New Jersey will control the balance of the time.
  There was no objection.
  Mr. CAMP. Madam Speaker, at this time I yield 1 minute to the 
gentleman from Texas (Mr. Gohmert).
  Mr. GOHMERT. Madam Speaker, this is well intended. But you read 
section 501, and it basically says if you make too much to get free 
health care but you make too little to be able to buy it, you're going 
to get taxed under this bill. It means well. But it does damage.
  For those who have paid into Medicare for 40 years or so, who 
expected to have it, they get cut hundreds of billions of dollars, but 
illegals are going to get covered. Come on now.
  In the 1960s they meant well with the Great Society, but they offered 
a check for every child a woman could have out of wedlock. Meaning 
well, wanting to help them, but they lured them into a rut with no way 
out, and they came to my court to be sentenced.
  We hurt people when we do the wrong things. For the Declaration of 
Independence, our Founders pledged their lives, their fortunes, their 
sacred honor. This is a ``declaration of dependence'' that pledges 
Americans' lives, Americans' fortunes, and there is no honor in that.
  Mr. ANDREWS. Madam Speaker, I yield myself 3 minutes.
  Madam Speaker, the people of the country and Members of the House 
deserve a vigorous debate. They also deserve an accurate record. And I 
think the time has come to begin to clarify and correct some of the 
series of assertions that have been made here that are simply not 
correct.
  There was an assertion made from the minority side a few minutes ago 
that no one knows what will happen to those who are on TRICARE or 
veterans health benefits. The gentleman may not know, but we do. 
Nothing will change for a person under TRICARE or veterans benefits if 
they do not wish to have it changed.
  There was a statement made on the other side that the bill will 
``cover illegal aliens.'' That is incorrect. There is no subsidy and 
there is no coverage for an undocumented person.
  There have been numerous statements made on the other side that there 
will be massive tax increases on the American people. Here is the fact: 
the fact is that there is a surtax in this bill that helps to pay for 
coverage of uninsured people and for better quality care. It affects 
the top .3 percent of households in this country. If you're an 
individual and you make more than $500,000 a year adjusted gross 
income, if you're a couple and you make more than $1 million a year 
adjusted gross income, it affects you.
  The statement has been made repeatedly the bill will add to the 
deficit. That's not the truth. That's not what the Congressional Budget 
Office says. They say the contrary. They say that the net effect of 
this bill is it will reduce the deficit in the first 10 years by in 
excess of $100 billion and that in the second 10 years, the bill will 
reduce the deficit by somewhere in the neighborhood of one-quarter of 1 
percent of GDP.
  The statement has been repeatedly made that it is a crime not to have 
health insurance. Here's the accurate statement: because there is a 
penalty imposed on individuals who don't meet the individual mandate, 
and, by the way, that individual mandate has within it very generous 
subsidies and it has a hardship exemption, but it has been said it is a 
crime not to have health care. That is not accurate. It is a crime to 
willfully and intentionally evade taxation, just as it is with every 
other tax.
  It has been said this is a government takeover of health care. That 
is false. This is a consumer takeover of health care. And those who 
would be apologists for the insurance industry don't like that. The 
American people do and will.
  Madam Speaker, I reserve the balance of my time.
  Mr. CAMP. Madam Speaker, at this time I will place in the Record a 
letter from the Joint Committee on Taxation, which on page 3 indicates 
that both misdemeanor and felony penalties with imprisonment of up to 5 
years will be imposed.

                                    Congress of the United States,


                                  Joint Committee on Taxation,

                                 Washington, DC, November 5, 2009.
     Hon. Dave Camp,
     House of Representatives,
     Washington, DC.
       Dear Mr. Camp: This is in response to your request for 
     information relating to enforcement through the Internal 
     Revenue Code (``Code'') of the individual mandate of H.R. 
     3962, as amended, the ``Affordable Health Care for America 
     Act.'' You specifically inquired about penalties for a 
     willful failure to comply.


       Tax on individuals without acceptable health care coverage

       H.R. 3962 provides that an individual (or a husband and 
     wife in the case of a joint return) who does not, at any time 
     during the taxable year, maintain acceptable health insurance 
     coverage for himself or herself and each of his or her 
     qualifying children is subject to an additional tax. The tax 
     is equal to the lesser of (a) the national average premium 
     for single or family coverage, as applicable, as determined 
     by the Secretary of Treasury in coordination with the Health 
     Choices Commissioner, or (b) 2.5 percent of the excess of the 
     taxpayer's modified adjusted gross income over the threshold 
     amount of income required for the income tax return filing 
     for that taxpayer. This tax is in addition to both regular 
     income tax and the alternative minimum tax, and is prorated 
     for periods in which the failure exists for only part of the 
     year. In general, the additional tax applies only to United 
     States citizens and resident aliens. The additional tax does 
     not apply to those who are residents of the possessions or 
     who are dependents, nor does it apply to those whose lapses 
     in coverage are de minimis or those with religious conscience 
     exemptions. The additional tax does not apply if the 
     maintenance of acceptable coverage would result in a hardship 
     to the individual or if the person's income is below the 
     threshold for filing a Federal income tax return.


        Range of civil and criminal penalties for noncompliance

       You asked that I discuss the situation in which the 
     taxpayer has chosen not to comply with individual mandate and 
     not to pay the additional tax. The Code provides for both 
     civil and criminal penalties to ensure complete and accurate 
     reporting of tax liability and to discourage fraudulent 
     attempts to defeat or evade tax. Civil and criminal penalties 
     are applied separately. Thus, a taxpayer convicted of a 
     criminal tax offense may be subject to both criminal and 
     civil penalties, and a taxpayer acquitted of a criminal tax 
     offense may nontheless be subject to civil tax penalties. In 
     cases involving both criminal and civil penalties, the IRS 
     generally does not pursue both simultaneouly, but delays 
     pursuit of civil penalties until the criminal proceedings 
     have concluded.
       The majority of delinquent taxes and penalties are 
     collected through the civil process. In determining whether a 
     penalty applies along with an adjustment to a tax return, the 
     examining agent is constrained not only by the applicable 
     statutory provisions, but also by the written policy of the 
     IRS not to treat penalties as bargaining points but instead 
     to develop the facts sufficiently to support the decision to 
     assert or not to assert a penalty. The goal is consistency, 
     fairness and predictability in administration of penalties.
       If the government determines that the taxpayer's unpaid tax 
     liability results from willful behavior, the following 
     penalties could apply.


                            Civil penalties

       Section 6662(a)--an accuracy related penalty of 20 percent 
     of the underpayment attributable to the health care tax, 
     based on negligence or disregard (the former includes

[[Page 27464]]

     lack of a reasonable attempt to comply and the latter 
     includes any intentional disregard of rules or regulations) 
     or substantial understatement, if the understatement of tax 
     is sufficiently large.
       Section 6663--a fraud penalty of 75 percent of the 
     underpayment, if the government can prove fraudulent intent 
     to avoid taxes by clear and convincing evidence.
       Section 6702--a $5,000 penalty for taking a frivolous 
     position on a tax return, if the underpayment is intended to 
     delay or impede tax administration and the return on its face 
     indicates that the self-assessment is substantially 
     incorrect.
       Section 6651--delinquency penalty of .5 percent of the 
     underpayment, each month, up to a maximum of 25 percent of 
     the underpayment.


                           Criminal penalties

       Prosecution is authorized under the Code for a variety of 
     offenses. Depending on the level of the noncompliance, the 
     following penalties could apply to an individual:
       Section 7203--misdemeanor willful failure to pay is 
     punishable by a fine of up to $25,000 and/or imprisonment of 
     up to one year.
       Section 7201--felony willful evasion is punishable by a 
     fine of up to $250,000 and/or imprisonment of up to five 
     years.


            Application of penalties under current practice

       The IRS attempts to collect most unpaid liabilities through 
     the civil procedures described above. A number of factors 
     distinguish civil from criminal penalties, in addition to the 
     potential for incarceration if found guilty of a crime. 
     Unlike the standard in civil cases, successful criminal 
     prosecution requires that the government bear the burden of 
     proof beyond a reasonable doubt of all elements of the 
     offense. Most criminal offenses require proof that the 
     offense was willful, which is a degree of culpability greater 
     than that required in a civil penalty cases. For example, a 
     prosecution for willful failure to pay under section 7203 
     requires proof beyond a reasonable doubt both that the 
     taxpayer intentionally violated a known legal duty and that 
     the taxpayer had the ability to pay. In contrast, in applying 
     the civil penalty for failure to pay under section 6651, the 
     burden is on the taxpayer: the penalty applies unless the 
     taxpayer can establish reasonable cause and lack of willful 
     neglect with respect to his failure to pay.
       Criminal prosecution is not authorized without careful 
     review by both the IRS and the Department of Justice. In 
     practice the application of criminal penalties is infrequent. 
     In fiscal year 2008, the total cases referred for prosecution 
     of legal source tax crimes were as follows.
       Investigations initiated--1,531.
       Indictments and informations--757.
       Convictions--666.
       Sentenced--645.
       Incarcerated--498.
       Percentage of those sentenced who were incarcerated--77.2.
       Of the 666 convictions reported above for fiscal year 2008, 
     fewer than 100 were convictions for willful failure to file 
     or pay taxes under section 7203. Civil penalties outnumber 
     criminal penalties imposed. For example, in fiscal year 2008, 
     compared to the 666 convictions, approximately 392,000 
     accuracy related penalties were assessed on individual 
     returns. Also in fiscal year 2008, the IRS assessed 5,502 
     penalties under section 6702 for frivolous positions taken on 
     returns.
       I hope this information is helpful for you. If I can be of 
     further assistance, please contact me.
           Sincerely,
                                               Thomas A. Barthold.

  Madam Speaker, at this time I yield 1 minute to the gentleman from 
Texas (Mr. Poe).
  Mr. POE of Texas. Madam Speaker, in my prior life I was a judge for 
22 years. I tried only criminal cases.
  This bill forces everyone that can to buy insurance whether they want 
to or not. If they don't, they're taxed. But that tax is really a fine. 
Be that as it may, if they don't pay the fine, they're in violation of 
the IRS Code and they can pay another $250,000 fine and go to a Federal 
penitentiary for 5 years.
  That is government oppression of the people, forcing them to buy 
insurance whether they want to or not. That is repressive government 
control, and that's the way that I see it. If they don't submit, they 
are forced to go to jail.
  You know, this bill is about government control. It's not about 
choice. It's oppression. It's not about liberty. The Constitution 
starts out with ``We the people.'' If this bill passes, especially that 
section, let's scratch out ``We the people'' and write in the phrase 
``We the subjects of Big Government.''
  And that's just the way it is.
  Mr. ANDREWS. Madam Speaker, I'm pleased at this time to yield 1\1/2\ 
minutes to the gentlewoman from Ohio (Ms. Fudge), who's one of the 
authors of the small business provisions in the bill.
  Ms. FUDGE. There comes a time, Madam Speaker, when we must choose 
that which benefits the greater good or look for selfish reasons to 
support the status quo. Now is that time and I choose the greater good.
  When I go home, Madam Speaker, I will be able to say that I was asked 
to make health care more affordable and I said ``yes.'' This bill makes 
health care affordable for 36 million more Americans by ensuring that 
working-class citizens will never have to pay more than 12 percent of 
their income on health care premiums and that people whose incomes are 
400 percent of poverty or less will receive their premiums in the form 
of subsidies. More than 163,000 households in my district alone will 
benefit from these subsidies.
  When asked to increase access to care, I said ``yes.'' ``Yes'' to the 
people of America who will no longer worry about being denied coverage 
because of preexisting conditions. ``Yes'' to the people of America 
whose families can now have regular checkups and free preventative 
care. Madam Speaker, I said ``yes'' to those who for the first time 
will have a family doctor instead of using the emergency room for 
routine matters.
  When asked to help the laid-off worker, the small business owner, the 
working poor, and those who can't make ends meet in this very 
struggling economy, I said ``yes.'' When asked to ensure that those who 
have health care today but may be dropped tomorrow are taken care of, I 
said ``yes.'' When asked to exhibit the courage needed to fight for 
change, I said ``yes.''
  When the history of the 111th Congress is written, I choose to be in 
that number that said ``yes'' to the people of America.

                              {time}  1745

  Mr. CAMP. Madam Speaker, I yield 1 minute to the gentleman from 
California (Mr. Rohrabacher).
  Mr. ROHRABACHER. Madam Speaker, this attempt at sliding Americans 
into dependence on a government-controlled health care system brings 
bait-and-switch to a new low. We have heard about the flaws of our 
current health care system: high cost; lack of portability; lose a job, 
lose insurance; and discrimination against those with preexisting 
conditions. Yes, many of the heart-wrenching stories we are hearing to 
justify this legislation are real. But correcting those maladies only 
requires specific reform. It doesn't require transforming health care 
in America into a bureaucratically managed health care system that will 
cost hundreds of billions of dollars more, including billions to 
provide health care for illegal aliens while at the same time cutting 
Medicare by hundreds of billions of dollars.
  This so-called reform will destroy the freedom of the American people 
to make health decisions with their doctor and the doctor of their 
choice. It will transform our system rather than reform it, and what we 
will end up with is a system that is massively more expensive, less 
effective, and will be based on government controls and rationing, 
rather than the patient-doctor relationship.
  Mr. ANDREWS. Madam Speaker, nurses make a great contribution to our 
health care system, and a gentlewoman who is a nurse has made a great 
contribution to this bill. I yield 2 minutes to the gentlewoman from 
New York (Mrs. McCarthy).
  Mrs. McCARTHY of New York. I thank my colleagues, Mr. Andrews, and I 
also thank George Miller for also working with us.
  We have known for years that we have a shortage of doctors, 
especially primary care doctors, and we have had a shortage of nurses. 
This bill is going to help that.
  You know, when we talk and I hear some of the charges coming from the 
other side, I am wondering where have I been all of these months when I 
sat through the committee hearings and heard what we are doing.
  I want to say with the Education and Labor Committee, the Nurse 
Training and Retention Act and the Student-to-School Nurse Ratio 
Improvement Act is in this bill, H.R. 3962. The Nurse Training and 
Retention Act will provide grants so we can have more new nurses, but 
to have more new nurses,

[[Page 27465]]

we have to have those who are educated to teach those nurses. We have 
that in this bill, too.
  I also want to say that for years I have been fighting with the 
insurance companies to make sure that children who are born with 
disfigurements on their face can have corrections so long term they 
won't have those scars, physically and mentally, and to help those 
families adjust to the child. In this bill, we will be able to say that 
the plastic surgeons can work on these children.
  Think about a child who is born without an ear. The insurance 
companies say that is cosmetic. That is not cosmetic. The ear is 
actually part of the body so you can actually hear better. But the 
emotional scars that happen to the children that are born with these 
deformities, that is wrong.
  If we can't take care of our children in this country, if we can't 
make sure our seniors on Medicare get the kind of care that they need--
I will tell you, I just went through surgery. I went to get my 
prescriptions filled, and my pharmacist said to me, How lucky, you 
don't have to pay anymore for your prescriptions until January 1. Why? 
Because I have coverage, because I have health care from the Federal 
Government. We can do better, and we should.
  The SPEAKER pro tempore. The Chair recognizes the gentleman from 
Minnesota (Mr. Kline) for 40 minutes.
  Mr. KLINE of Minnesota. Madam Speaker, I yield myself such time as I 
may consume.
  Madam Speaker, we have before us today more than 2,000 pages of 
legislative text that will give us public policy that costs more than 
$1 trillion and creates a huge morass of government bureaucracies. Over 
a hundred new offices, bureaus, commissions, and programs. Let's look 
briefly at just one of these new offices.
  The Democrats empower a new super bureaucrat with unprecedented 
authority over personal health care decisions, the health choices 
commissioner, heading up the Orwellian health choices administration.
  In the short time we have had since this legislation was made public, 
we have combed these pages--in the first part of these 2,000 pages--to 
see if we could get a picture of the responsibilities, authorities, and 
powers that were granted to this individual. As you can see, Madam 
Speaker, we actually had to go back to the supply store to get enough 
of these tabs.
  This super bureaucrat, this health choices commissioner, it turns out 
will have powers to define, deny, deem, determine, assess, administer, 
and establish our health care benefits for all Americans.
  It is no wonder that millions of Americans are afraid of a government 
takeover of our health care. How can they not fear such a thing? This 
is unprecedented, this amount of power granted to one bureaucrat. And, 
of course, there are other bureaucrats in this bill.
  I don't believe that this bill should see the light of day. It 
certainly should not pass. It is a recipe for job losses. It is a clear 
power grab by Washington bureaucrats. It is a power grab. We ought to 
discard it altogether. Press the reset button, start over. We can do 
better. The American people deserve better. Let's vote ``no'' on this 
power grab by Washington bureaucrats.
  I reserve the balance of my time.
  The SPEAKER pro tempore. The gentleman from New Jersey has 1\1/2\ 
minutes remaining.
  Mr. ANDREWS. Madam Speaker, at this time I would like to yield to a 
gentleman who authored a very key provision about saving money through 
medical records technology, the gentleman from Oregon (Mr. Wu) for 1\1/
2\ minutes.
  Mr. WU. Madam Speaker, I rise today in strong support of health 
insurance reform. In 20, 40, 60 years, this legislation will stand 
beside Social Security, the GI bill, and Medicare as a pillar of 
American health care and humane values. The bill creates a new health 
insurance exchange or marketplace to expand access and provide people 
with a menu of quality health insurance options so they can choose the 
plan that best meets their own needs.
  The bill would create affordability credits to ensure that all 
Americans have more affordable health care coverage.
  The bill will set a yearly limit on how much you can be charged for 
out-of-pocket expenses because no one should go broke because you get 
sick.
  In short, what health insurance reform means for Americans is more 
security and stability. Americans should not have to wait any longer 
for these reforms. We have been waiting since Theodore Roosevelt. We 
have been waiting since Franklin Roosevelt. We have been waiting since 
Harry Truman. We have been waiting since Lyndon Johnson. We have been 
waiting since Jimmy Carter. We have been waiting since Bill Clinton. It 
is time to stop the waiting and it is time to act.
  The SPEAKER pro tempore. The time of the gentleman from New Jersey 
has expired.
  Mr. KLINE of Minnesota. Madam Speaker, I yield for the purpose of a 
unanimous consent request to the gentleman from California (Mr. Lewis).
  Mr. LEWIS of California. Madam Speaker, I rise to oppose H.R. 3962.
  Madam Speaker, our health care system is the envy of much of the 
world. That does not mean it is perfect.
  Major challenges such as pre-existing conditions and portability can 
be dealt with by breaking down barriers between states and through 
nationwide underwriting.
  California-style liability reform provides a model to reduce the cost 
of defensive medicine and can significantly reduce the cost of health 
care.
  Tax incentives can be used to encourage broader participation by 
families, without federal mandates.
  The Speaker and her congressional advisors are committed to 
government-run health care. We can solve existing problems without 
adding a trillion dollars on the backs of average American taxpayers.
  Vote ``no'' H.R. 3962. Help save us from single payer healthcare.
  Mr. KLINE of Minnesota. I reserve the balance of my time.
  The SPEAKER pro tempore. The gentleman from New Jersey (Mr. Andrews) 
is recognized for 40 minutes.
  Mr. ANDREWS. Madam Speaker, at this time it is my honor to yield 4 
minutes to a person who has spent a distinguished career in this House 
fighting for this day, who is one of the principal authors of this 
bill, the leader of our committee, the chairman of the Committee on 
Education and Labor, the gentleman from California (Mr. George Miller).
  Mr. GEORGE MILLER of California. Madam Speaker, I thank the gentleman 
so much for his contribution to this legislation, to the debate in this 
House, and to the role he has played in informing our Members and the 
public about this bill.
  I want to begin by giving thanks, Madam Speaker, particularly on my 
committee, I want to thank the staff that have worked so terribly hard, 
Michele Varnhagen, Megan O'Reilly, Jody Calemine, Aaron Albright, 
Meredith Regine, and Rachel Racusen, who have all supported this 
tremendous team and the professional staff of the Committees on Ways 
and Means and Energy and Commerce, and certainly to my colleagues, 
Chairman Rangel and Chairman Waxman, and to our subcommittee chairmen, 
Mr. Andrews, Mr. Pallone and Mr. Stark. It has truly been an honor to 
have been involved in this debate and sit in the same room with the 
dean of our House, John Dingell, and to be able to craft this 
legislation. It is an honor I will remember the rest of my life, and I 
thank the Democratic leadership for giving us the space to bring 
President Obama's bill to this House so we can pass it and change 
America. And I want to thank Speaker Pelosi. Without her leadership, 
her tenacity and her passion, we would simply not be here today.
  We are about to make history, and the reason we are about to make 
history is because many of us have so much confidence in the great 
things that America is capable of achieving. America has been 
challenged throughout its history to achieve great things on behalf of 
Americans, on behalf of the world community. We have risen to that 
challenge. But throughout that history, one challenge has eluded us: 
the challenge to come and to finally provide access to affordable 
health care

[[Page 27466]]

for all of our citizens, for all Americans, to provide them the kind of 
security that they would know with this legislation, to provide them 
the understanding that never again will they live in fear that they 
will be without health care, for whatever circumstances take place in 
their lives.
  And every Member in this Chamber on both sides of the aisle have 
encountered our constituents over our public careers as they have told 
us terrible stories, dramatic stories, painful stories, sad stories, 
about how their family has been crushed, or their friends or their 
neighbors that they care about or work with, by circumstances beyond 
their control. How, when one circumstance leads to another, how in 
America today when the layoff notice comes, you are also on notice that 
you will lose your insurance. Your world is turned upside down 
immediately. You struggle to find employment or retraining. You 
struggle to refigure your family's finances. And you know if your 
children are sick, they won't be able to go to the doctor--you won't be 
able to afford it. If your spouse is in the middle of treatment, that 
treatment can be curtailed, no matter what the illness, no matter how 
important the treatment is. It can go in a flash.
  We cannot continue to ask American families to continue to live on 
that edge of uncertainty, of insecurity, of the possibility of fiscal 
ruin. A small event, because of the lack of health care, can explode 
into the life of a family, into the life of a community when it happens 
over and over and over again.
  But this legislation says that's not going to happen again in our 
future. We are going to become the architects and the builders of a 
system that will provide care to these people, will provide services to 
these people, will provide security for these people so that these 
American families can go to work with confidence. They can buy a home 
with confidence. They can think about their kids' education with 
confidence, and know it will not be all wiped out in a flash because 
their insurance was canceled.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. ANDREWS. I yield the gentleman an additional 1 minute.
  Mr. GEORGE MILLER of California. That is what this legislation is 
about. We can talk about all of the internal merits and the back and 
forth. But at the end of the day, for the first time in our history, we 
deliver to all Americans the security that their family will have an 
opportunity to continue on a stable financial track and that they can 
make the kinds of plans that we want to make for our children, our 
grandchildren, that their neighbors might be able to make.
  But in America today, because of the absence of this policy, because 
of the absence of a comprehensive health care bill that provides 
universal access, because of the failure of a bill that will help 
families that are struggling to meet the demand to pay the premiums, 
because of that failure, as The Wall Street Journal said, we pay a huge 
price in innovation because people know they will be penalized if they 
start a new business, if they take an idea and try to take it to 
fruition, if they switch jobs for a better opportunity maybe career-
wise but that doesn't have insurance, if they want to go to work for a 
start-up where they can't provide insurance.
  Let's give America for the first time health care security for their 
families, their friends, their kids, and their neighbors.
  Madam Speaker, I rise in support of this historic legislation to fix 
our broken health insurance system and finally bring affordable health 
coverage to every American.
  We are truly on the verge of making history.
  Never before has the House or Senate approved a bill to guarantee 
every American access to affordable health care.
  Never.
  Not that we haven't tried.
  The fight to reform this Nation's health care system has spanned 
nearly 100 years, across generations and many great leaders, from Teddy 
Roosevelt to Franklin Roosevelt to John F. Kennedy to President Clinton 
to my own personal hero, Ted Kennedy.
  But time and again these efforts were stymied by special interests.
  The need for reform is dire.
  Hundreds of thousands of people are losing insurance each month.
  At least 36 million Americans have no coverage at all--including 
nearly 50,000 people in my district in Northern California.
  Over half of all personal bankruptcies are due to a medical incident.
  Businesses are choking on bloated health care costs.
  Innovation is being stifled. Our competitiveness is undermined.
  But this year is different. This time is different.
  The American people literally cannot afford to wait any longer, and 
today we will cast a history-making vote to guarantee all Americans 
access to quality, affordable health insurance.
  We must not fail again.
  An unprecedented effort by the House led us to this milestone.
  Three committees and our diverse Caucus worked together in an 
extensive and coordinated fashion, with one purpose--to fulfill a 
decades-old and yet still urgent promise.
  We engaged the public in one of the most transparent debates of 
federal legislation in history, including over 2,000 events across the 
U.S. since July alone.
  The result is a bill that reflects what we have heard from workers 
and families, from small business owners and economists, from seniors 
and college students, from doctors and nurses.
  The Affordable Health Care for America Act will directly meet the 
needs of Americans and the goals that President Obama set for reform:
  It lowers costs for families and businesses,
  Protects people's choices of doctors and health plans, reduces the 
deficit, and
  Ensures access to quality, affordable health insurance for all 
Americans.
  For the first time in U.S. history, all uninsured Americans will be 
able to purchase quality, affordable coverage through a new Health 
Insurance Exchange, where they will be able to choose from a menu of 
options: a public health insurance option or several private plans.
  And for those that already have insurance, our bill will grant them 
the security of knowing that their coverage will always be there.
  Never again will Americans worry about losing their health care if 
they change or lose their job.
  Never again will someone be denied health care coverage because of a 
pre-existing condition.
  Never again will a patient have to worry about their insurance 
company rescinding their policy when they need coverage the most.
  Never again will a small business owner have to worry about 
unpredictable and unaffordable premiums.
  Our bill, H.R. 3962, will end the many injustices that workers, 
families, and businesses face in today's system.
  It will finally make health insurance work for consumers--not 
insurance CEOs.
  Let me be specific about what our reforms will mean for the American 
people:
  No more co-pays or deductibles for preventative care;
  No more rates increases because of a pre-existing condition, gender, 
or occupation;
  An annual cap on out-of-pocket expenses;
  Guaranteed affordable dental, hearing and vision care for children;
  Lower prescription drug costs for seniors;
  Young people will be able to stay on their parents' insurance through 
their 27th birthday; and
  A ban on lifetime caps on what insurance companies will pay, so 
patients will never again be one treatment away from medical 
bankruptcy.
  As I mentioned earlier, this legislation meets our commitment to 
fiscal responsibility.
  Every piece of this bill is fully paid for through a combination of 
revenue raised by placing a surcharge on the wealthiest Americans and 
savings generated by making Medicare and Medicaid more efficient.
  These reforms will strengthen Medicare for seniors and shift our 
system's focus from quantity of health procedures to quality of care 
and producing healthier outcomes for patients.
  The Congressional Budget Office reports that our bill will reduce the 
deficit by more than $100 billion over the next decade and slow the 
growth of health spending, leading 11 chief health care economists to 
declare our legislation ``vital to the Nation's fiscal and economic 
future.''
  As with previous efforts to reform health care, this bill received an 
enormous amount of public scrutiny.
  In the last few months, opponents of health reform have conjured up 
every falsehood imaginable about this bill in an effort to scare the 
American people and once again try to stymie reform.

[[Page 27467]]

  But as I said, I believe that this year is different. Our legislation 
has been tested in public and the momentum continues to grow in support 
of the bill.
  The American people have seen through the lies and distortions.
  And they are not fooled by the hoax of an 11th hour Republican bill 
that is nothing more than a cruel rebuke to the needs of the American 
people.
  Their bill would do nothing but maintain the status quo and guarantee 
insurance profits at the expense of tens of millions of hard working 
Americans.
  The public understands the true meaning of our bill.
  They know it will cover 96 percent of Americans.
  They know that, under our bill, if they lose their job they will 
continue to have health coverage for their children, spouses and 
families.
  They know that this bill means that if they have cancer, the 
insurance company can no longer pull the rug out from under them while 
they're in the middle of treatment.
  They know that this bill will protect them, through any economic 
cycle.
  Nearly 50 years ago, as he was fighting to expand health care 
benefits, President Kennedy said,

       All of the great revolutionary movements of the Franklin 
     Roosevelt Administration we now take for granted. But I 
     refuse to see us live on the accomplishments of another 
     generation. I refuse to see this country and all of us shrink 
     from the struggles which are our responsibility in our times.

  We must not shrink from the struggle for health reform, which is our 
responsibility in our time. This is our moment to revolutionize health 
care in this country.
  We have arrived at this historic moment thanks to the hard work of so 
many people.
  I would like to thank my good friends and colleagues, Chairman Rangel 
and Chairman Waxman, and our three subcommittee chairs, Rob Andrews, 
Frank Pallone and Pete Stark, and especially Dean Dingell. We could not 
have had better teammates in this journey.
  I would also like to thank the Democratic Leadership, our Speaker, 
Ms. Pelosi, the Majority Leader, Mr. Hoyer, our Whip, Mr. Clyburn, and 
all the members of leadership for the countless hours they spent 
working with the committee chairs to arrive at this point today.
  And of course we could not have completed the work on this bill 
without the work of our incredibly talented staff, who worked long 
nights and weekends for months on end. They are the unsung heroes of 
this process, and I know all our colleagues join me in thanking them 
for their extraordinary work.
  From my staff I would like to thank Mark Zuckerman, Alex Nock, Danny 
Weiss, Michele Varnhagen, Megan O'Reilly, Jody Calemine, Tico Almeida, 
Meredith Regine, James Schroll, Rachel Racusen, Aaron Albright, Amy 
Peake, Courtney Rochelle, and Mike Kruger.
  Finally, I'd like to pay tribute to my mentor and friend, Sen. Edward 
M. Kennedy.
  Health care was the cause of Ted's lifetime. Our effort would have 
been impossible had he not carried the torch of justice and equality 
for all those years.
  I know I am not alone when I say that I sincerely wish Ted Kennedy 
could be with us today to see his dream of quality, affordable health 
care for all become a reality.
  Madam Speaker, this is the most important bill I have ever worked on 
during my many years of service in Congress.
  I could not be prouder to have helped to write this bill, to 
encourage each of my colleagues to support it, and to cast my vote in 
favor of the Affordable Health Care for America Act.
  We stand at the doorstep of history.
  Let us go in.

                              {time}  1800

  Mr. KLINE of Minnesota. Madam Speaker, at this time, I yield 3 
minutes to the ranking member of the Health Subcommittee, certainly a 
member of the committee, the gentleman from Georgia (Dr. Price).
  Mr. PRICE of Georgia. Madam Speaker, health care at its very core is 
a compassionate and a moral human endeavor. As a physician, I can tell 
you that I never saw a Democrat or a Republican disease. The medical 
decisions that each American makes for themselves and for their 
families are some of the most important and personal decisions ever 
made, and there are principles of health care that we should follow. 
Think about those principles of accessibility and affordability and 
quality and responsiveness and innovation and choices. Think about 
those principles. None of those principles are improved by the further 
intervention of the Federal Government, which is why we should adopt 
and concentrate on positive, patient-centered health care reform.
  It is so very important that principles be in place that will ensure 
that patients and their families and their doctors are able to make 
those personal medical decisions unencumbered by a stifling and 
oppressive Federal Government. But sadly, this bill will not allow 
those independent decisions and is wrong in so many ways.
  This bill, on page 94, will make it illegal for any American to 
obtain health care not approved by Washington. This bill, on page 301, 
will force Americans to purchase health coverage that Washington picks, 
not that you select for yourselves. This bill, on pages 297 and 313, 
places job-killing taxes on virtually every single business. This bill, 
on page 211, will force millions of Americans to lose their current 
personal private health coverage.
  This bills comes with a price tag of $1.3 trillion, which will be 
borne by our children and our grandchildren. This bill, on page 520, 
slashes billions of dollars from Medicare that will necessitate health 
care rationing for seniors. And this bill, on page 733, empowers the 
Washington bureaucracy to deny lifesaving patient care if it costs too 
much.
  This bill is not a health care bill. This bill is an affront on the 
morality of the provision of American health care.
  As a physician, when patients and their families and their doctors 
are not allowed to independently decide what care should be provided, 
we lose more than our health care system; we lose our morality and we 
lose our freedom.
  This bill, whether known or not, is an oppressive affront to every 
single American. The positive vote, the bipartisan vote on this bill is 
``no.''
  Mr. ANDREWS. Madam Speaker, I am pleased to yield to a Member who 
understands the immorality of 47 million uninsured. The gentleman from 
Michigan (Mr. Kildee) is recognized for 1 minute.
  Mr. KILDEE. I thank the gentleman.
  Madam Speaker, I rise today in strong support of H.R. 3962, the 
Affordable Health Care for America Act.
  Choices regarding health care are some of the most personal decisions 
we make. The ability to choose one's doctor and decide on a course of 
treatment with one's physician is an undeniable American right, and so 
is access to quality affordable health care.
  Most of us can agree that our current health insurance system is 
broken. The cost of health insurance has skyrocketed in recent years, 
leaving many families struggling to afford coverage or forcing them to 
go without. Others are denied insurance due to preexisting conditions, 
saddling them with terrible medical debt when they need treatment.
  These treatments, along with other factors, Madam Speaker, have led 
to nearly 50 million Americans without any health insurance; 71,000 
live in my district.
  I urge the passage of this bill.
  Lack of adequate health coverage leads many people to wait until an 
emergency to seek medical treatment, turning what could have been a 
simple doctor's visit into a costly trip to the E.R. What many people 
do not realize is that when patients cannot pay their bills, the 
American taxpayer is charged for a portion of that cost. Medical 
providers also absorb some of the costs, forcing them to raise the 
prices of services and thereby increasing costs for everyone and 
driving up health insurance premiums. This problem will only get worse 
over time, and health care will continue to become more and more 
expensive.
  The House health insurance reform legislation addresses this issue by 
increasing competition between insurers, thereby lowering costs. It 
also prevents insurers from denying or dropping coverage due to pre-
existing conditions. By treating conditions earlier at a doctor's 
office, instead of at the emergency room, it will save money for the 
patient, the taxpayer and the medical providers, ultimately bringing 
down health care costs for everyone.
  This is an issue that Congress has been tackling since the days of 
Harry Truman and even before and I am proud to stand with my colleagues 
in passing this long awaited bill.
  Mr. KLINE of Minnesota. At this time, I am very pleased to yield 1

[[Page 27468]]

minute to the gentlelady from North Carolina, a former member of this 
committee and now a member of the Rules Committee, Dr. Foxx.
  Ms. FOXX. I thank my colleague from Minnesota.
  The people of America are struggling with 70 percent effective 
unemployment brought on by actions of this Democratically controlled 
government. And what do the Democrats want to do? Give us more 
government. They expect us to believe that more government control of 
our lives is good. More government control is not good.
  We've been successful as a Nation because of our freedom. Taking away 
freedom will weaken us as a people and a country. The American people 
know that and have told us that. They're opposed to this bill.
  Medicare, the kind of treatment they want us to have, denies 
treatment more than twice as often as most private insurance. That will 
be our future: rationed health care and destruction of freedom.
  My colleagues should say no to the Pelosi-Obama freedom-killing, job-
killing H.R. 3962.
  Mr. ANDREWS. Madam Speaker, when people were about to be deprived the 
freedom to choose a public option, the Progressive Caucus stood up. The 
leader of the Progressive Caucus that led that effort will now be our 
next speaker.
  The gentlewoman from California (Ms. Woolsey) is recognized for 2 
minutes.
  Ms. WOOLSEY. Thank you to Congressman Rob Andrews, who kept this 
clear and made it understandable for every single person in this 
country. Thank you, Congressman.
  Well, let's put aside all the numbers and fuzzy terminology and let's 
talk about what this bill really means to average Americans.
  Madam Speaker, I will never forget 40 years ago waking up in the 
middle of the night with a start night after night after night because 
I did not have health insurance for my three small children, and it was 
not anything that had to do with anything that we had caused. I would 
wonder what would happen, what if my children got ill or one of them 
was injured because of no health insurance? Well, this bill that we're 
talking about today, with it, our family would have been secure. We 
would have been much healthier because we would have known that we had 
health insurance.
  So, Madam Speaker, let's take a family of two, two working parents, 
two children. With this bill, if one of the children gets sick, the 
parents won't have to worry about arguing with the health insurance 
company for treatment. If the mother gets breast cancer, the family 
won't have to worry that their health insurance company will cancel 
their coverage because it doesn't want to pay for her treatment. If one 
of the parents loses his or her job, and along with it the family's 
health insurance, they will be able to go into the health exchange and 
choose between private and public plans. If the family can't afford to 
pay the premiums, there will be affordability credits to help them.
  That security would have meant a better life for me. It would have 
meant a better life for my children that year. We want to make sure 
that every child has that security.
  Mr. KLINE of Minnesota. At this time, I am very pleased to yield 1 
minute to a very important member of the committee, the gentleman from 
Wisconsin (Mr. Petri).
  Mr. PETRI. I thank my colleague from Minnesota.
  Madam Speaker, unemployment is 10.2 percent, the highest in 26 years, 
yet here we are being asked to vote on a bill which will radically 
alter and disrupt one-sixth of our economy, hit businesses with costly 
new regulations, ratchet up monstrous Medicaid mandates on the 50 
States, raise taxes on job creators, impose skyrocketing insurance 
premiums on individuals and families, and destroy popular Medicare 
Advantage plans, all this while failing to bend the cost curve down and 
providing no real liability reform.
  At a time of record deficits, this bill spends over $1 trillion to 
provide health insurance to less than 15 percent of Americans. To pay 
for this budgetary train wreck, it imposes $730 billion in new taxes 
and relies on a series of budget gimmicks in a slippery attempt to 
claim it won't contribute to our deficit tsunami.
  This legislation will bring about a radical intrusion of government 
into every sector of health care. It puts bureaucrats between patients 
and their doctors. It doesn't make sense, isn't very smart.
  Let's not pass this monstrosity.
  I certainly agree that it is time to fix the health care system in 
the United States so that all Americans have access to quality, 
affordable health care. In order to achieve this goal, I strongly 
believe that any bill that is approved by Congress must institute 
reforms that will address the rising cost of health care.
  The majority of Americans have some kind of health insurance they are 
generally satisfied with. What they really care about is rising costs. 
Spending on health care services already accounts for about 17 percent 
of gross domestic product (GDP)--an expected total of about $2.6 
trillion in 2009. Health care inflation has outpaced general inflation 
by approximately 2.5 percent a year. Government spending on health care 
continues to grow exponentially and without action, spending on 
Medicare and Medicaid will rise from 4 percent to 19 percent of GDP in 
2082.
  However, the bill we are considering today takes us in the entirely 
wrong direction by instituting reforms that will increase health care 
spending while doing little to bend the cost curve. This legislation is 
best categorized as an entitlement expansion rather than health care 
reform. At a time of record deficits, H.R. 3962 spends $1.055 trillion 
to provide health insurance to less than 15 percent of Americans. 
Furthermore, almost 15 million of these individuals will receive 
insurance coverage by expanding the eligibility of Medicaid. This 
results in the largest expansion of Medicaid since its inception almost 
forty years ago. In fact, according to the Congressional Budget Office, 
the bill will increase the federal budgetary commitment to health care 
by $598 billion in the first ten years alone!
  To pay for this budgetary train wreck, H.R. 3962 imposes $729.5 
billion in new taxes on small businesses, individuals who cannot afford 
health insurance, and employers who cannot afford to provide coverage 
that meets new insurance standards. In Wisconsin, the ``surtax'' that 
provides the largest source of funding for the bill will hit 11,900 
small businesses--at a time when unemployment is hovering around nine 
percent. Individuals who are dependent on medical equipment such as 
wheelchairs and hearing aids will also face increased costs because of 
additional taxes in this bill--at a time when many families are 
struggling to pay their monthly bills.
  Furthermore, H.R. 3962 relies on a series of budget gimmicks to make 
it appear that the bill would not increase the federal deficit. First, 
the legislation fails to account for this year's projected 21 percent 
cut to Medicare physician reimbursements, which if allowed to go 
through would severely threaten seniors' access to physicians. However, 
preventing this and future cuts will cost over $200 billion. Instead of 
making this fix in H.R. 3962 and accounting for its cost, the 
Democratic House leadership introduced it as a stand-alone bill without 
offsets--despite the fact that the Senate already rejected this 
approach. H.R. 3962 also proposes over $400 billion in cuts to 
Medicare. However, as many acknowledge, Congress has a history of 
reversing itself on unpopular cuts to Medicare, so it is very 
questionable as to whether these savings will be realized. The 
legislation also authorizes a new long-term care program which is 
funded through a voluntary payroll tax. H.R. 3962 uses these pay roll 
contributions for other spending priorities in the bill, instead of the 
benefits that will eventually have to be paid out under the new 
program. Even the Democratic Chairman of the Senate Budget Committee, 
Kent Conrad, called the inclusion of this program a ``Ponzi scheme.'' 
Finally, only 7/10th of a percent of new spending occurs in the first 
three years, while most of the tax increases begin at enactment, 
representing a debt and ``tax'' time bomb.
  Besides increasing taxes and adding to the exploding deficit, this 
legislation represents a radical intrusion of government into every 
sector of health care. H.R. 3962 gives the government unprecedented 
authority over the regulation of health insurance. The top-down 
bureaucratic model of mandating extensive cost sharing and coverage 
requirements will do very little to ensure high quality care and will 
certainly lead to increased costs.
  We should be doing the exact opposite and giving consumers, rather 
than government bureaucrats or insurance companies, more responsibility 
for decisions regarding their health

[[Page 27469]]

care. This bill does nothing to incentivize consumer driven health 
plans which encourage individuals to take care of themselves, save for 
future medical expenses and comparison shop to find the best health 
care at the most reasonable cost. Most importantly, consumer driven 
plans put into motion the incentive structure throughout the health 
care delivery system that will slow the rising cost of health care.
  In fact, many of the reforms and new mandates in H.R. 3962 will 
actually raise the cost of health insurance for those that are now 
covered. Multiple studies have demonstrated that younger and healthier 
Americans could see their health care premiums triple, and a family of 
four could see its health care premiums more than double. While H.R. 
3962 mandates that all citizens purchase ``acceptable coverage,'' in 
reality many young and healthy individuals may find it more economical 
to forego coverage and pay the penalty which is less expensive than the 
cost of buying health insurance. Should younger and healthy people 
forego coverage, premiums for everyone else will increase. In fact, 
because of the bill's ban on insurance companies discriminating against 
pre-existing conditions, younger healthier people will have even more 
of an incentive to wait until they are sick to purchase health 
insurance.
  The legislation also breaks the President's promise that if you like 
your health insurance you will be able to keep it. The legislation 
makes significant cuts to Medicare Advantage Plans which will surely 
eliminate or reduce benefits to the 216,000 beneficiaries in Wisconsin.
  Furthermore, the legislation places an 8 percent tax on businesses 
that don't offer acceptable coverage, as defined by federal 
bureaucrats. According to the Galen Institute, a non-profit think tank, 
``data from a 2009 Kaiser Family Foundation survey suggest that at 
least 30 percent of firms with fewer than 200 employees that now offer 
insurance would fail the test for family coverage, and about 20 percent 
would fail individual coverage.'' However, instead of complying with 
the new mandates, many employers will likely stop offering health 
insurance to their employees because the 8 percent payroll tax penalty 
is less than the cost to provide coverage. Furthermore, the extensive 
new federal record keeping and audit requirements provide further 
incentives to stop offering coverage. In fact, a study by Blue Cross 
and Blue Shield demonstrated that ``complying with the new actuarial 
standards in the bill would increase average costs by 17 percent for 
individuals and almost 10 percent for small employers.''
  Over 80 percent of the money spent on health care in the United 
States today is spent on the delivery of health care. Yet, what we see 
in today's bill is just ``more of the same'' in the delivery of care 
instead of making fundamental changes to reward high quality, low cost 
care. The bill authorizes hundreds of Medicare pilot programs to test 
different ways to pay doctors and hospitals for quality of care. But 
once again, these pilots are governed from the top-down and typically 
take years to initiate and rarely result in reforms applied throughout 
the system. Instead, we should be supporting efforts that are coming 
out of both the states and multi-collaborative projects between 
networks of hospitals, businesses and physicians. Wisconsin hospitals 
such as ThedaCare, Marshfield Clinic, Gunderson Lutheran, and Aurora 
Health Care have long been engaged in transforming the delivery of care 
to get rid of the inefficiencies and provide low cost, high quality 
care. We should be supporting these reforms from the bottom-up, instead 
of repeating the work that has already been done.
  And finally, I have grave concerns that the legislation will allow 
for government funding of abortions and threaten current conscience 
protections for health care providers. I strongly believe that the Hyde 
Amendment should be codified in this legislation.
  Today, I will vote in support of Congressman Boehner's substitute 
amendment which is a good step forward in lowering health care premiums 
for families and small businesses, increasing access to affordable high 
quality care, and promoting healthier life styles--without adding to 
the deficit.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Members are reminded to heed the gavel.
  Mr. ANDREWS. Madam Speaker, I yield myself 30 seconds before the next 
introduction.
  There is a credibility issue here. The minority says the bill doesn't 
have enough prevention, but the American Cancer Society supports the 
bill. The minority says it destroys the doctor-patient relationship, 
but the American Medical Association supports the bill. The minority 
says it's bad for America's seniors and for Medicare, but the AARP 
supports the bill. I think there is a credibility issue, and it doesn't 
work for the minority.
  At this time, I would be happy to yield 1\1/4\ minutes to the 
gentleman from Pennsylvania (Mr. Sestak).
  Mr. SESTAK. Madam Speaker, a little shy of 3 years ago, I came to 
this Congress to pay back a debt. After three decades in the U.S. 
military, my young 4-year-old was struck with the same brain tumor 
Senator Ed Kennedy had. Because of the wonderful health care plan that 
this Congress provides our families in the military, she was given a 
chance.
  I was taken in the U.S. military by how and why we do that. It's not 
because we're generous. It's because we reap great dividends for this 
Nation. This Congress sent me off for 11\1/2\ months to a war, and 
while I was gone, my daughter and my wife were taken care of and my 
mind was on the mission. In the military, we reap the benefit of 
healthy, focused warriors.
  I am taken with this bill. It gives us healthy, productive workers. 
It actually combines, in my mind, the best of America's character--
rugged individualism allied with the common enterprise of this Nation. 
It gives us the quality of life that in the military reaps such great 
dividends. This bill, to me, is no different, and it's time.
  Mr. KLINE of Minnesota. Madam Speaker, at this time, I yield 2 
minutes to the ranking member of the Armed Services Committee and the 
former ranking member of the Education and Labor Committee, the 
gentleman from California (Mr. McKeon).
  Mr. McKEON. Madam Speaker, I thank the ranking member for yielding.
  It's been said that Abraham Lincoln said, ``You cannot bring about 
prosperity by discouraging thrift. You cannot strengthen the weak by 
weakening the strong. You cannot help the wage earner by pulling down 
the wage payer. You cannot further the brotherhood of man by 
encouraging class hatred. You cannot help the poor by destroying the 
rich. You cannot keep out of trouble by spending more than you earn. 
You cannot build character and courage by taking away man's initiative 
and independence. You cannot help men permanently by doing for them 
what they could and should do for themselves.'' Madam Speaker, what 
we're doing here violates all of these principles that Abraham Lincoln 
spoke so eloquently about.
  I rise today in strong opposition to this Pelosi bill of over 2,000 
pages. At a time when we are suffering the highest unemployment in this 
country since 1983, the American people can't afford these massive new 
spending increases, and I refuse to pass this great burden on to my 
children and grandchildren.
  I offered two amendments to try to improve this bill: one to require 
Members of Congress to enroll in the public option like we're going to 
require all of you to do, and one that said that illegal immigrants 
would not receive new benefits under this new bill; commonsense 
provisions that were voted down by the Democrats in the Rules 
Committee. In fact, Democrats voted down every single Republican 
amendment but one. How is that for bipartisanship?
  This legislation increases taxes, kills jobs, and costs over $1 
trillion in money we don't have. The Republican plan will cut costs 
through tort reform, negotiating across State lines, and through 
purchasing power.
  Support the Republican alternative and oppose the Pelosi plan. This 
is an absolute disaster.

                              {time}  1815

  Mr. ANDREWS. Madam Speaker, before I yield to my next speaker, I 
yield myself 30 seconds.
  With all due respect, what is an absolute disaster are the repeated 
misrepresentations of certain things that are in this bill, and we just 
heard one. No one is forced to join the public option. No one. It is 
not in the bill; and I would, frankly, invite the minority to show us 
where it is.
  Secondly, Members of Congress are positioned exactly the way everyone 
else is with the public option. When and if the time comes that the 
Federal Government is a participating employer in the exchange, we can 
either

[[Page 27470]]

choose the public option or not. The House deserves an accurate record.
  I yield 1\1/2\ minutes to a woman who stood for fiscal soundness not 
only here in Washington but in New Hampshire for her State budget, the 
gentlewoman from New Hampshire, Carol Shea-Porter.
  Ms. SHEA-PORTER. Madam Speaker, I rise today to support the 
Affordable Health Care for America Act. This is a historic moment for 
our Nation.
  In my district, this bill will provide coverage for 37,000 uninsured 
residents; 128,000 households will qualify for credits to help them 
afford the coverage of their choice. We will invest more in community 
health centers. We make Medicare stronger, which is why AARP has 
endorsed this bill. We start to close the Medicare part D doughnut hole 
in 2010, and it will be completely closed by 2019. We will provide a 50 
percent discount for name-brand drugs for those in the doughnut hole, 
and we eliminate copayments for preventative care.
  Today, we make history for our seniors, for our children, for the 
middle class--for all Americans. Today, we vote for an America where 
discrimination based on preexisting conditions is a thing of the past. 
Today, we vote for an America where getting sick doesn't mean losing 
your home. Today, after decades of debate, we finally vote for a 
healthier America.
  Mr. KLINE of Minnesota. Madam Speaker, before I yield to the 
gentlewoman from Washington, I yield for a unanimous consent request to 
the gentleman from Kentucky (Mr. Rogers).
  Mr. ROGERS of Kentucky. Madam Speaker, I rise in opposition to this 
freedom-taking bill.
  We can all agree that health care costs are too high and that we need 
to open up access for more Americans. That being said, we need to pass 
a bill that actually cuts costs and increases access rather than a 
government-run takeover of health care. I cannot support Speaker 
Pelosi's monstrosity of a bill because it puts a Washington bureaucrat 
between individuals and their doctor, it adds to our enormous debt in 
Washington, and, even more frightening, it will limit health care 
availability in rural regions like southern and eastern Kentucky.
  In these challenging economic times, with double digit unemployment, 
out of control government spending sprees, and bailout after bailout, 
we should not pass a bill that will kill jobs and raise taxes. Speaker 
Pelosi's government-run health care bill not only imposes new penalties 
and taxes on small businesses, it raises taxes on already struggling 
individuals and families. Whether someone wants health insurance or 
not, they'll be forced to purchase it, and the federal government will 
garnish wages or send them to jail if they don't comply. Even more 
troubling, the more vulnerable and ailing one is, the more they'll pay, 
as this bill imposes new taxes on critical medical supplies, like 
wheelchairs, oxygen tanks, hospital beds, and prosthetic limbs. As if 
that wasn't enough, the bill opens the floodgates of taxpayer money for 
illegal immigrants to abuse the system and obtain free government 
health insurance--all on the backs of law-abiding Americans. Lastly, I 
am scared for our seniors as this bill makes devastating cuts to the 
Medicare program to the tune of $500 billion, and puts the popular 
Medicare Advantage program on life support, virtually eliminating its 
existence.
  I support the Republican alternative health care bill that focuses on 
lowering health care premiums for families and small businesses, 
increases access to affordable high-quality health care, and promotes 
healthier lifestyles without adding to Washington's crushing debt. The 
plan I support guarantees access to affordable care for those with pre-
existing conditions, ends junk lawsuits against our doctors, allows 
small businesses to band together to purchase insurance for their 
employees and allows individuals to shop for insurance across state 
lines. Simple and less costly initiatives such as these will lower 
insurance premiums by at least 10 percent, and provide health insurance 
to millions more Americans.
  This bill reflects a fundamental and drastic change in our way of 
life, and is the largest government intrusion into the private lives of 
our citizens ever. I, for one, am truly frightened by the potential 
consequences.
  Mr. KLINE of Minnesota. I am now pleased, Madam Speaker, to yield 2 
minutes to a member of the committee, the ranking member on a 
subcommittee, the gentlewoman from Washington, Cathy McMorris Rodgers. 
  Mrs. McMORRIS RODGERS. I thank the gentleman for yielding.
  Madam Speaker, we just need to slow down. The American public has 
made it clear that they want the right health care reform bill enacted, 
not just any bill.
  Look at the stimulus bill that was rushed through Congress. Look at 
what has happened. They said, Oh, unemployment won't go over 8 percent. 
We are now at 10.2 percent. We have lost 3 million jobs, and we have a 
$1.4 trillion deficit.
  Like my mom used to say, You rush, you make mistakes.
  This health care reform bill will be no different. It spends $1.3 
trillion. It taxes employers $750 billion, many of whom are small 
business owners, at the very time that we need these small business 
owners to be creating jobs. We need jobs. Isn't it interesting that 
even the administration's own economic adviser has estimated that this 
bill will cost America an additional 5.5 million jobs.
  Other reforms in the bill all but eliminate Medicare Advantage, 
hurting 20,000 seniors in eastern Washington and millions across the 
country. For rural communities, the bill calls on the Institute of 
Medicine to study payment disparities in rural regions. So we are 
spending $1.5 trillion, and the only relief we get is another study? My 
list of concerns goes on and on.
  The Republicans have a better way, one that lowers premiums for 
families by as much as 10 percent; one that saves billions in medical 
liability reform, allowing people to purchase health insurance across 
State lines; one that continues the continuity and coverage; and it's a 
solution that doesn't indebt our children and our grandchildren.
  Madam Speaker, just this week, thousands of people stood on the 
Capitol steps. They called on Congress to oppose this legislation. I 
urge us to heed their warning. Vote ``no.'' Let's slow down the 
process, and let's get the right kind of reform, not just any kind of 
reform.
  Mr. ANDREWS. Madam Speaker, I yield myself 15 seconds.
  The gentlewoman just quoted an unnamed phantom Obama administration 
adviser. Christina Romer, the CEA chairperson for the Obama 
administration, says this bill will increase the GDP between 1-2 
percent and will add several million jobs.
  I am pleased to yield 1\1/2\ minutes to a strong voice for working 
families in this country, the gentleman from Illinois (Mr. Hare).
  Mr. HARE. Thank you, Congressman Andrews.
  Madam Speaker, when I was growing up as a young boy, my parents lost 
their home. My father was ill. He couldn't make the payments. I 
remember coming home the day of my older sister's wedding to see a 
process server with a notice to evict and 30 days to leave.
  Two days before my father died, I sat by his bed, and he told me, 
There are two promises I want you to make to me: take care of the girls 
and your mother, and no matter what you do, please see that this will 
not happen to another family.
  Tonight, in a few hours, I will have the opportunity to keep that 
promise to my dad and to the tens of thousands of other people who have 
lost their homes and everything they had simply because they were sick. 
All the fear-mongering. All the misstatements of facts and figures. 
Health care in this country, my friends and fellow citizens, is a 
right. It is not a privilege.
  So, tonight, for my father and for the people who came after him, I 
will stand proud for this bill no matter the amount of shouting, of 
tearing this down and of calling the bill whatever you want to call it. 
I call it getting people exactly what this country promises them: life, 
liberty, and the pursuit of happiness.
  Mr. KLINE of Minnesota. Madam Speaker, I am pleased to yield 1 minute 
to a member of the committee, the gentleman from Michigan (Mr. 
Hoekstra).
  Mr. HOEKSTRA. I thank my colleague for yielding.
  Madam Speaker, today, I met Theresa. Theresa had a sign that read: I

[[Page 27471]]

love my country. On the other side, it read: My future. Her brother, 
Xavier, had a sign that read: Give me liberty, not debt.
  If we pass Pelosi health care tonight, tomorrow morning, we will 
still all love our country; but we will have jeopardized Theresa's 
future. A bailout, a stimulus, cap-and-trade, and Pelosi health care 
have jeopardized her future. For Xavier, we will have given him debt: 
another $1.2 trillion on top of the $1.4 trillion we gave him last 
year.
  I will vote ``no'' because I believe that that's the vote that says: 
I love my country. I will vote ``no'' because I believe that that is 
the vote that preserves our future. I will vote ``no'' because I know 
that that will preserve Xavier's liberty and not give him more debt.
  With that, I urge my colleagues to vote ``no'' on this bill.
  Mr. ANDREWS. Madam Speaker, I am pleased to yield 1\1/2\ minutes to a 
member who fought tirelessly for equality in Medicare reimbursement for 
the State of Iowa, the gentleman from Iowa (Mr. Loebsack).
  Mr. LOEBSACK. Thank you, Mr. Andrews.
  Madam Speaker, I am proud to be a part of this effort to improve 
health care in America, and I will support the bill before us because I 
have heard from countless Iowans about the desperate need to change the 
current system, and I believe this legislation before us today will 
provide true and comprehensive reform.
  However, since coming to Congress, I have told just about everyone I 
could and everyone who would listen to me that comprehensive reform 
could not be achieved without addressing geographic disparities in the 
Medicare payment system. Many other Members agreed, and we formed the 
Quality Care Coalition, and we brought about that change.
  There is much needed language in this bill to fix a broken Medicare 
payment system. By focusing now on the quality of services provided to 
patients instead of the quantity of services, this provision will 
provide a significant cost savings to Medicare, and it will benefit 
patients in Iowa and all across America.
  In particular, I want to thank my leadership; my chairman on the 
committee, George Miller; my friend Rob Andrews; Chairman Waxman; and 
Chairman Rangel for their work on this issue.
  I urge everyone to vote for this bill before us.
  Mr. KLINE of Minnesota. Madam Speaker, I yield 1 minute to a member 
of the committee, the gentleman from South Carolina (Mr. Wilson).
  Mr. WILSON of South Carolina. Madam Speaker, America's leading voice 
for small business, the National Federation of Independent Business, 
the NFIB, opposes H.R. 3962, the Pelosi takeover bill. The NFIB has 
sounded the alarm about the employer mandate, payroll tax penalty and 
unnecessary paperwork mandate crippling small businesses.
  The opposition letter from the NFIB warns that the Pelosi takeover 
includes multiple mandates. Economic research shows mandates are 
ultimately borne by the worker through job loss and lower wages. The 
NFIB also warns how the payroll tax penalty is a tax on jobs and job 
creation. Additionally, the unnecessary paperwork mandate will place a 
new paperwork burden on all small businesses at a time when they are 
struggling to stay afloat. The NFIB has estimated the takeover effort 
will kill 1.6 million jobs at a time of record unemployment.
  We should support health insurance reform, not a government takeover.

                                                 November 5, 2009.

                   Letter to House Opposing H.R. 3962

       Dear Representative: On behalf of the National Federation 
     of Independent Business (NFIB), the nation's leading small 
     business advocacy group, I am writing in opposition to the 
     Affordable Health Care for America Act (H.R. 3962). The 
     Affordable Health Care for America Act does not reflect the 
     access or affordability needs of NFIB's small businesses, and 
     a vote against H.R. 3962 will be considered an NFIB Key Vote 
     for the 111th Congress.
       NFIB has been a constructive participant in the healthcare 
     debate and has spent more than a decade voicing our need for 
     reform. With healthcare costs ranking as the No. 1 issue 
     facing small business, our employers must carefully weigh the 
     potential benefits of reform against the new costs imposed on 
     business owners in the legislation. NFIB members have 
     identified specific areas in H.R. 3962 that will raise those 
     costs:
       Employer Mandate: H.R. 3962 includes an employer mandate 
     that will require employers to pay for healthcare for full-
     time and part-time employees. An employer mandate does not 
     address the No. 1 issue facing small businesses: 
     unsustainable costs. This mandate affects those who do not 
     offer coverage today as well as those who already do provide 
     insurance, but aren't making contributions at contribution 
     levels outlined in the bill (72.5% for individual plans and 
     65% for family plans). Rather than help, this will penalize 
     employers already offering healthcare and force them to make 
     hard choices about how to afford the new government 
     requirements. Economic research has shown time and again that 
     mandates such as these are a ``one-two punch'' where the cost 
     is first borne by the employer, but is ultimately borne by 
     the employee--through job loss and lower wages.
       Payroll Tax Penalty: A payroll tax penalty is a tax on jobs 
     and job creation because they tax labor. The legislation 
     requires that all employers with a payroll of $500,000 or 
     more pay a payroll tax of up to 8 percent if they do not 
     provide ``qualified'' health insurance to their employees. No 
     matter how profitable or unprofitable a business might be, 
     they are forced to pay this tax. In addition, because the 
     exemption thresholds in H.R. 3962 are not indexed for 
     inflation, the exemption will become a healthcare equivalent 
     of the alternative minimum tax, hitting more and more 
     employers until there is no one exempted at all.
       Paperwork Mandate: H.R. 3962 places a new tax-compliance 
     paperwork burden on all small businesses. The ``corporate 
     reporting'' provision is an expansion on reporting 
     requirements (for transactions of more than $600), which 
     increases the cost of operating a small business and diverts 
     resources away from growing and creating jobs.
       Big Benefit Package and More Mandates: Small employers need 
     a guarantee that plans offered in an exchange will be less 
     costly, not more expensive, than what they are paying today. 
     Today, small businesses pay an average of 18 percent more for 
     their healthcare, leaving them continuously searching for 
     more affordable choices.
       H.R. 3962 gives a political board the power to define 
     ``coverage'' and will determine whether an employer plan is 
     ``acceptable.'' However, the bill does nothing to ensure that 
     the new plans will be less costly than what small employers 
     are paying today. In some cases, the legislation will also 
     require some small employers to cover benefits that are not 
     currently mandated under federal law.
       Takes Away Small Business Solutions: Small employers need 
     more, not fewer, affordable health insurance options. 
     However, the prohibition of HSA, FSA and MSA funds to 
     purchase over-the-counter medications, along with the $2,500 
     limit on FSA contributions, threatens to further limit the 
     ever-shrinking options employers have to provide meaningful 
     healthcare to their employees.
       Public Option: A government-run plan cannot compete fairly 
     with the private market, and threatens to destroy the 
     marketplace, further limiting choices. We believe that with 
     proper reforms the private market can be held accountable to 
     provide greater competition and lower-cost solutions where 
     insurers compete based on their ability to manage, rather 
     than shed risk. Instead, the excessively prescriptive 
     insurance reforms in H.R. 3962 will drive up costs.
       Surtax: Seventy-five (75) percent of small businesses are 
     structured as pass through entities and pay their business 
     taxes at the individual level. More than one-third of small 
     businesses employing 20 to 250 employees could face the tax. 
     Finally, since the tax is not indexed for inflation, the 
     effect of the tax will creep downward, making more and more 
     businesses vulnerable to a tax increase.
       Poorly-Structured Tax Credit: There are two reasons the 
     credit in H.R. 3962 is of limited value. First, the 
     availability of the credit is too short. A credit that is 
     only available for two years means that every small business 
     owner that claims the credit will see a large spike in their 
     out-of-pocket costs for health care in year three. Second, 
     the wage limits are too restrictive. Phasing the credit out 
     based on average wages of $20,000 or less severely reduces 
     the amount of a tax credit available for most small 
     businesses.
       NFIB will continue to advocate for reform because, as both 
     democratic and republican lawmakers have said, the status quo 
     is not acceptable. Our small business owners agree, but 
     reform must make the problem better, not worse. Because H.R. 
     3962 will not lower healthcare costs and threatens our 
     economic recovery, NFIB will consider a NO vote a vote in 
     support of small business. This will be an NFIB KEY VOTE FOR 
     THE 111TH CONGRESS.
           Sincerely,

                                                Susan Eckerly,

                                            Senior Vice President,
                                            Federal Public Policy.

  Mr. ANDREWS. Madam Speaker, I yield 2 minutes to a gentlewoman who 
authored a provision to expand small

[[Page 27472]]

business opportunities for affordable health insurance, the gentlewoman 
from Nevada (Ms. Titus).
  Ms. TITUS. Thank you, Mr. Andrews.
  Madam Speaker, for more than 6 months, I've discussed the need for 
health care reform with my constituents; and time and again I've heard 
from small business owners who are struggling to afford health care 
coverage.
  Over the last decade, the average health insurance premium has more 
than doubled for Nevada's small businesses. Without comprehensive 
reform, Nevada's small business health premiums are projected to again 
double over the next decade. In this year alone, small businesses 
across the country are being hit with a 15 percent average increase in 
premiums. It is clear that the status quo is unacceptable and 
unsustainable.
  I had concerns about earlier versions of this bill, but I am pleased 
that H.R. 3962 before us today is significantly improved and takes 
important steps to help make health insurance more affordable.
  I worked to raise the income level at which people are assessed a 
health care surcharge. The new threshold is significantly higher, up 
from $350,000 for couples to $1 million. This means that 98.8 percent 
of all small businesses will be exempt from paying any surcharge.
  The bill also now exempts small businesses with payrolls below 
$500,000 from the employer mandate. That means that 86 percent of all 
employers are exempt, and many small businesses which choose to offer 
insurance to their employees will be eligible for a tax credit to help 
offset those costs.
  I am especially proud that the provision I championed, which was to 
expand the health insurance exchange so that more businesses could 
participate, was included and strengthened in this bill. This will 
ensure that small businesses have additional options for purchasing 
health insurance at a lower cost.
  All of these improvements combined will strengthen small businesses 
so they will be critical engines of growth in our communities. It is 
time small businesses knew who really stood up for them and cared about 
them and their employees.
  I urge my colleagues to support this bill and to stand up for small 
business.
  Mr. KLINE of Minnesota. Madam Speaker, I yield 1 minute to a member 
of the committee, the gentlewoman from Illinois (Mrs. Biggert).
  Mrs. BIGGERT. I thank the gentleman for yielding.
  Madam Speaker, I rise in strong opposition to this $1.3 trillion 
government takeover of health care.
  Time and again, the President promised the American people that, if 
they like the health insurance they have, they can keep it. So I 
introduced an amendment in the Education Committee that said what he 
said: if you like the health insurance you have, you can keep it.
  The Democrats defeated this amendment with a unanimous vote.
  This bill does not keep the President's promise. Instead, it would 
allow a group of unelected government bureaucrats to determine if the 
health insurance you have is up to government standards. If they say 
it's not and if you don't buy what they say you should buy, you will be 
fined. If you don't pay the fine, it's jail time.
  I urge my colleagues to defeat the bill and to, instead, vote for the 
GOP alternative. Not only does it expand access to those who lack it 
and not only does it lower costs for everyone, but it cuts the deficit, 
preserves the doctor-patient relationship, and ensures that you can 
keep the coverage you have.

                              {time}  1830

  Mr. ANDREWS. Madam Speaker, a number of great and visionary men have 
stood at the podium where you stand now as Speaker of the House. Many 
of them tried to achieve significant health care reform; each of them 
failed. A lot of strong visionary men failed, so we will succeed with a 
strong, visionary woman.
  It is my privilege to yield 1 minute to the Speaker of the House of 
Representatives, Congresswoman Nancy Pelosi.
  Ms. PELOSI. I thank the gentleman for yielding, for his kind remarks 
and for his tremendous leadership on bringing this legislation to the 
floor. Thank you, Congressman Rob Andrews.
  Madam Speaker, today as we all know is an historic moment for our 
Nation and for America's families. For nearly a century, leaders of 
every party and political philosophy have, as far back as Teddy 
Roosevelt, called for health care for the American people.
  For generations, the American people have called for affordable, 
quality health care for their families. Today, the call will be 
answered. Today, we will pass the Affordable Health Care for America 
Act.
  This legislation is founded on key principles for a healthier 
America: innovation, competition and prevention. It improves quality, 
lowers cost, expands coverage to 36 million more people, and retains 
choices.
  Our innovation began in the recovery package in January with $19 
billion for health IT, the first step in lowering cost and improving 
quality, and $8 billion in investments for biomedical research. This 
legislation will mean affordability for the middle class, security for 
our seniors and honors our responsibility to our children, adding not 
one dime to the deficit.
  For all Americans, this legislation makes a big difference: no 
discrimination for preexisting medical conditions; no dropped coverage 
if you are sick; no copays for preventive care. There is a cap on what 
you pay in, but there is no cap on the benefit that you receive.
  It works for seniors, closing the doughnut hole, offering better 
primary care and strengthening Medicare for years to come. It works for 
women, preventing insurance companies from charging women more than men 
for the same coverage. No longer will being a woman be a preexisting 
medical condition.
  It works for young people, offers affordable choices and copays for 
preventive care to stop problems before they start, and allows young 
people to stay on their parents' insurance until their 27th birthday. 
It works for small business owners, providing access to affordable 
group rates and creating a tax credit to help them insure their 
employees. It works for consumers, keeping insurance companies honest 
and encouraging competition with a public option.
  This legislation puts you and your doctor in charge. No longer will 
the insurance companies come between you and your doctor.
  President Obama has said that health care reform is entitlement 
reform, and this legislation proves that point. It is fiscally sound, 
it is paid for, and it reduces the deficit by tens of billions of 
dollars over the next 10 years.
  This legislation is the result of extensive deliberation here in the 
Congress, where we have held more than 100 hearings and is the product 
of extensive input from the American people. Members of Congress have 
held over 3,000 town meetings. It has resulted in a better bill than 
H.R. 3200. However good or excellent that was, this bill is a better 
one with significant differences, and my colleagues have pointed them 
out, as did Congresswoman Dina Titus, who just spoke before me at the 
podium.
  We are brought to this historic moment in our Nation for our families 
because of the work of our chairmen: Chairman Henry Waxman of the 
Energy and Commerce Committee, Chairman Charlie Rangel of the Ways and 
Means Committee, Chairman George Miller of the Education and Labor 
Committee, and Chairwoman Louise Slaughter of the Rules Committee. I 
thank all of those committees, including the Rules Committee, for being 
in so late so that we could have this legislation on the floor today 
and for their ongoing service to the Congress.
  More than 300 groups representing tens of millions of Americans have 
expressed their support for the bill: the AARP, American Medical 
Association, the American Nurses Association; the list of medical 
groups goes on and on. The American Cancer Society Cancer Action 
Network, American Heart Association, American Diabetes Association. And 
I am particularly proud the

[[Page 27473]]

Consumers Union has endorsed the legislation. My colleagues, this 
morning we were part of history, and we are this evening as well.
  But a particularly poignant moment occurred when Chairman Dingell 
took the Chair to preside over the debate, the beginning of the debate 
for health care. When he was a young man as a Member of Congress, he 
gaveled Medicare into law. It had been, as one of our colleagues said, 
in his DNA, this pursuit of health care for all Americans. His father 
had introduced the bill over and over again when he was in Congress 
and, as his successor, he continued that great legacy. Today he will 
see a lifelong dream of generations in his family come true as we begin 
the process of making this a reality.
  It's impossible to talk about health care reform in America without 
talking about Senator Edward Kennedy. His leadership and his 
contribution to this debate is boundless. Health insurance reform was 
the cause of his life. He called it ``the great unfinished business of 
our society.'' On this issue he said what is at stake ``is the 
character of our country.'' When the President came to address the 
joint session, he quoted those comments by Senator Kennedy from a 
letter that the Senator had sent to him. What the Senator also said in 
the letter that was sent to President Obama before he died was this:
  ``I entered public life with a young President who inspired a 
generation and the world. It gives me great hope that as I leave, 
another young President inspires another generation and, once more on 
America's behalf, inspires the entire world.''
  He acknowledged President Obama's ``unwavering commitment and 
understanding that health care is a decisive issue for our future 
prosperity.''
  President Obama's leadership gives our Nation hope. Today, with this 
legislation, we will give them health. President Obama has said, ``We 
will measure our success in the progress that is made by America's 
working families.''
  Today, with the passage of the Affordable Health Care for America 
Act, we will make history. We will also make progress for America's 
working families.
  I urge my colleagues to support this important legislation.
  Mr. KLINE of Minnesota. Madam Speaker, at this time I am pleased to 
yield 1 minute to someone who tells me that he is, in fact, very proud 
he doesn't have a section in this bill, a member of the committee, the 
gentleman from Indiana (Mr. Souder).
  Mr. SOUDER. This is indeed a historic day. It's a crossroads in 
America. What you just heard from our distinguished Speaker was we, the 
government, will do this. We, the government, will do that. We, the 
government, will do this. We, the government, will do that. Instead of 
having the private sector do this, instead of having competition, 
instead of having capitalism do this, we, the government, will fix 
everything. We, the government, will provide everything.
  We are in an economic crisis in this country. Just yesterday, for the 
first time, an over 10 percent unemployment. In my eight counties, over 
half are over 15 percent unemployment.
  So what are we doing today? Taxing small business, the number one 
producer of jobs, adding regulations to those businesses, adding 
expenses to those businesses, taxing medical technology, which will 
reduce R&D, reduce jobs, reduce quality of health care.
  What are we doing today? We are not going to require identification 
for illegal immigrants. We are going to hope that they self-report. 
With 1,990 pages of ignoring the voices of American people, you get 
higher taxes, fewer jobs, an unconstitutional takeover of 17 percent of 
our economy, a trillion dollars of debt, and free health care for the 
illegals who took your jobs.
  Mr. ANDREWS. Madam Speaker, I am pleased to yield 2 minutes to the 
gentleman who made sure that the ban on discrimination based on 
preexisting conditions will take effect as soon as this bill does, the 
gentleman from Connecticut (Mr. Courtney).
  Mr. COURTNEY. Madam Speaker, 45 percent of Americans suffer from some 
form of chronic disease, leaving them exposed to preexisting condition 
discrimination. The Commonwealth Fund found that 12.6 million non-
elderly adults were, in fact, discriminated against by insurance 
companies because of preexisting conditions in the last 3 years.
  This health care reform bill will abolish the barbaric discriminatory 
practice of denying insurance and charging more for insurance to 
Americans based on medical underwriting. Like Jim Crow laws, like 
separate but equal laws, like laws denying women the right to vote or 
own property, the practice of denying coverage because of a person's 
internal biology, high blood pressure, diabetes or cancer will be 
forever abolished.
  Section 211 of this bill ends this practice permanently in 2013; and 
section 106, which I wrote with Mr. Andrews' help, immediately provides 
relief by amending existing law to shorten the look-back period for 
group health plans from 6 months to 30 days and reduces the exclusion 
of coverage for preexisting conditions from 18 months to 90 days.
  This balanced, well-thought-out reform of the Health Insurance 
Portability and Accountability Act of 1996 will provide tangible, real 
change for Americans terrified of losing their coverage because of a 
layoff or a job change.
  What does the Republican plan do? Does it adopt section 106 or 211? 
No. On page 145 of the Republican bill, they call for--are you ready--a 
GAO study of the issue of preexisting conditions. The time for delay 
and dilatory studies is over. It is time to act.
  As U.S. President Abraham Lincoln once said, it is time to make a 
more perfect union, and pass the Affordable Health Care for America 
Act.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1\1/2\ 
minutes to a distinguished member of the committee, the gentleman from 
Delaware (Mr. Castle).
  Mr. CASTLE. Mr. Speaker, I rise in opposition to the legislation but 
in strong belief that the vast majority of us in Congress are committed 
to reducing the skyrocketing costs of health care today and expanding 
access to insurance coverage for those in need.
  Additionally, I am certain that if we focused on the on the many 
shared bipartisan goals, we could pass a health reform package that 
took commonsense steps without making financial commitments that this 
country is unable to afford. Such items include insurance market 
reforms such as preventing denial of care for preexisting conditions, 
purchasing insurance across State lines, encouraging regional exchanges 
between States and portability, small business pooling and tax credits, 
negotiating drug prices, eliminating the $60 billion in Medicare fraud 
each year, rewarding efforts to prevent common disease and illness, 
enrolling those who qualify into existing programs like Medicaid and 
SCHIP, tax benefits for needy individuals for help purchasing 
insurance, and limiting abusive lawsuits.
  Instead, we are confronted with a bill that overreaches by creating 
new government programs costing over $1 trillion paid for from tax 
increases and cuts to Medicare which are more gimmicks than real 
entitlement reform. Independent analysis of H.R. 3962 continues to show 
that reforms will result in higher costs for too many patients in 
addition to increasing the Federal debt which continues to rise 
dramatically under this Democratic administration and Congress.
  Universal health care will not happen overnight. An incremental 
approach that expands access to health care coverage, contains costs 
and limits government involvement should be at the forefront of lasting 
and meaningful program. The process to date has been driven by 
politics. It is not too late to enact policies that enjoy broad 
bipartisan support.
  Mr. ANDREWS. Mr. Speaker, our next speaker fought hard to make sure 
the vast majority of entrepreneurs in small businesses were exempt from 
any taxes under this bill. I am pleased to yield 1 minute to the 
gentleman from Colorado (Mr. Polis).

[[Page 27474]]



                              {time}  1845

  Mr. POLIS. Mr. Speaker, I would like to thank Mr. Andrews, the 
committee staff, and Chairman Miller for their hard work on this bill.
  Where are we today? Our country spends more and gets less from health 
care. We spend more and get less. Many small businesses and individuals 
are unable to afford insurance. Americans are fed up with 15 to 20 
percent increases in costs every year, and that is for those of us 
lucky enough to have insurance. People with preexisting conditions 
often can't get coverage, or the very condition they need coverage for 
is excluded.
  Where does this bill take us? It encourages competition among 
insurance companies, giving us more choices and more stability so we 
can choose from hundreds of different policies, including shopping 
across State lines.
  It covers most of the uninsured by empowering them to choose the 
provider of their choice. It prevents pricing discrimination based on 
preexisting conditions. It allows small businesses to have the same 
purchasing power as large corporations and saves them money. It reforms 
our legal system to reduce the cost of frivolous lawsuits. It supports 
doctor and nurse training, reduces the deficit by over $10 billion, and 
applies free market principles to establish a playing field for health 
care that is good for practitioners and consumers.
  I encourage my colleagues to support health care.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield 1 minute to a member of 
the committee and the ranking member of the subcommittee, the gentleman 
from Kentucky (Mr. Guthrie).
  Mr. GUTHRIE. Mr. Speaker, I have heard from many of my constituents 
who are worried and anxious about Speaker Pelosi's health care bill.
  Speaker Pelosi's bill spends $1.2 trillion, cuts Medicare benefits, 
includes a $34 billion unfunded Medicaid mandate and increases premiums 
for those already struggling to pay for health insurance. On top of all 
of that, the bill raises taxes for just about everyone. The bill taxes 
individuals who choose not to purchase health insurance, taxes small 
businesses, taxes medical devices, and taxes health savings plans. The 
bill is the exact opposite of what the American people said they 
wanted.
  The Republican alternative addresses Americans' number one priority 
for health care reform: lowering the cost for premiums they pay now. 
The Congressional Budget Office has confirmed that our plan will lower 
health care premiums and reduce the deficit without taxing families and 
small businesses.
  I am voting ``no'' on Speaker Pelosi's bill because of the 
devastating consequences it will have on Kentucky's families, seniors, 
and small businesses.
  Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1 minute to a 
gentleman who has led the fight to help small businesses in this bill, 
the gentleman from New York (Mr. Bishop).
  Mr. BISHOP of New York. Mr. Speaker, we all know that our fiscal 
future presents enormous challenges. The skyrocketing costs of our 
health care system puts constraints on our Federal budget, on our 
family budgets, and it prevents necessary investments in our future and 
the future of our children.
  The key to fiscal stability is entitlement reform. The key to 
entitlement reform is health care reform, and the first step in health 
care reform is the legislation before us. With nearly one-fifth of our 
national spending going towards health care, reducing the rate of 
increases in health care costs is an absolute necessity.
  Let's be honest with our constituents. Reducing corporate welfare and 
promoting efficiencies in Medicare spending is not equivalent to 
cutting benefits or covering fewer services. Rather, the Affordable 
Health Care for America Act is a thoughtful approach to ensuring 
Medicare works better for seniors and for those who provide care.
  Most importantly, the Affordable Health Care for America Act promotes 
stability and peace of mind for the family who just learned their child 
has diabetes or the husband whose wife has just been diagnosed with 
breast cancer. No longer will such devastating news be followed by the 
fear of impending bankruptcy.
  Vote ``yes'' on H.R. 3962.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Kansas (Ms. Jenkins).
  Ms. JENKINS. Mr. Speaker, the health care system in America needs 
reform, but the Pelosi plan is the wrong prescription. Unlike the 
Republican plan, this bill does nothing to reduce health care costs.
  While there are many reasons I am opposed to this bill, the most 
glaring is we can't afford it. Unemployment has hit 10.2 percent, the 
highest level since 1983; yet Democrats are forcing through yet another 
job-killing bill that, according to modeling created by the President's 
own economic advisers, will kill an additional 5.5 million jobs.
  Kansas just announced it is facing a $460 million budget shortfall; 
yet this body is set to send my State another unfunded mandate 
estimated to cost $230 million.
  And the deficit just exceeded $1.4 trillion; yet the majority wants 
to pass this $1.3 trillion government takeover of health care.
  Let's reject this fiscally irresponsible legislation.
  Mr. ANDREWS. Mr. Speaker, may I inquire as to how much time each side 
has left?
  The SPEAKER pro tempore (Mr. Pastor of Arizona). The gentleman from 
New Jersey has 18 minutes remaining, and the gentleman from Minnesota 
has 21 minutes remaining.
  Mr. ANDREWS. Mr. Speaker, I am very pleased to yield 1 minute to the 
newest member of our committee, who has made a tremendous contribution 
to this bill already, the gentlelady from California (Ms. Chu).
  Ms. CHU. Mr. Speaker, I rise in strong support of the Affordable 
Health Care for America Act. The clock is ticking for Americans and the 
children of my district. Families have been suffering, waiting for 
changes in our health care system so they can care for their children. 
They have been waiting for Congress to act.
  They are mothers like Maria, whose child has leukemia and worries 
that excessive copays will make her go bankrupt.
  They are children like Stacey, who has been waiting to get glasses 
and can't see the chalkboard at school, but she can't get them because 
her parents' insurance doesn't provide vision care.
  They are parents like Barbara and Jim, whose 20-year-old has diabetes 
and is no longer eligible for health insurance since he graduated from 
college.
  With the passage of this bill, out-of-pocket expenses will be capped 
at $10,000, vision care for children will be covered, and older 
children will be covered up until age 26. Maria will not go bankrupt, 
Stacey will get glasses, and a son with diabetes can get treated. 
Children and families will get the quality health care they deserve.
  Let's pass this health care bill now.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I am pleased to 
yield 1 minute to a member of the committee, a practicing physician 
himself, the gentleman from Louisiana (Dr. Cassidy).
  Mr. CASSIDY. Mr. Speaker, as a practicing physician, I know that this 
bill has tremendous consequences for patients and for the economy. It 
is estimated that the $730 billion in new taxes in this bill will kill 
5.5 million jobs. The CBO estimates that this will have an annual 
inflation rate of 8 percent, an annual inflation rate that more than 
doubles costs in 10 years.
  The Republican bill expands access by lowering premiums 10 percent. 
This bill expands access by forcing businesses and individuals to 
purchase, and if they do not, the long arm of the State reaches out and 
grabs them and shakes out fees and penalties.
  Now, it was said this morning by a Democratic colleague that we need 
to redefine freedom. We are going to need all kinds of new definitions. 
We are going to redefine freedom as the ability to do what the 
government tells you to do. We are going to redefine helping the 
economy as higher taxes and destroying jobs. We are going to redefine 
bending the cost curve as more than doubling costs in 10 years.

[[Page 27475]]

  Consider not the rhetoric, but the facts. Please reject this bill.
  Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1\1/2\ minutes to the 
gentleman from New Jersey, my neighbor and friend, Mr. Holt.
  Mr. HOLT. Mr. Speaker, the question so many are asking is, Can we 
afford this health care reform? I would say not only can we afford it, 
we can't afford not to pass it.
  Consider where we are today: Businesses, large and small, feel a 
heavy weight around their necks trying to afford health care for their 
employees. It hurts our economy. It costs jobs. Businesses and families 
are paying a hidden tax of over $1,000 each per year for the care of 
the uninsured. Costs continue to go up because our procedure-based 
system rewards the ordering of unnecessary and expensive tests that not 
only don't help the patient, they can be detrimental. Any family, even 
well-off families who think they have good health coverage, can find 
themselves in bankruptcy from a bad accident or arbitrary actions of 
the insurers.
  All of this would change under this bill. This bill would reduce 
costs in a number of ways: By reducing the ranks of the uninsured, 
whose more expensive care we all pay for; by increasing the insurance 
competition through the new marketplace with a large interstate risk 
pool; by removing the antitrust exemption; and by moving toward more 
efficient record-keeping and by moving toward outcome-based, health 
outcome-based, patient-centered care.
  In addition to all this, the revenues raised by this bill exceed the 
expenditures, so passing this will reduce the deficit by billions of 
dollars below what it would be if we do not pass this tonight.
  We can't afford not to pass this health care reform. The bill will 
reduce the costs individuals, families and businesses face and reduce 
the government deficit.
  Mr. Speaker, I rise today in strong support of the Affordable Health 
Care for America Act, H.R. 3962, legislation that would provide secure 
and stable health coverage regardless of whether one changes jobs or is 
between jobs, ensure Americans will never be denied care if they get 
sick, and extend coverage to those Americans not well served by the 
current health care system.
  This is a historic debate we are having. For the past century, since 
Teddy Roosevelt ran for President in 1912, our nation has been debating 
how to ensure that sick Americans can access the care they need. As a 
U.S. Representative and the husband of a primary care physician, I have 
heard many stories from hard-working New Jerseyans about the need for 
reform. Some Americans have access to excellent care, often thanks to 
the advanced biotechnology and pharmaceutical products created in New 
Jersey, while others lack even basic care. One of the goals of the 
health care reform is to help all Americans gain stable access to 
medical care and life-saving medicines.
  At a July roundtable in Trenton, a spouse of a cancer patient told me 
that when she and her husband came home from the hospital after one 
extensive treatment, they returned to foot-high stacks of insurance 
paperwork and $150,000 of out-of-pocket charges for her husband's 
needed care. A self-employed woman from East Brunswick wrote to me 
recently to let me know she pays $2,000 a month for her family's 
coverage and still has to pay out-of-pocket to see many of her 
physicians. These stories are a reminder that health care reform is 
about real people who are disserved by the broken health insurance 
system.
  These are not isolated stories. While in the U.S., we will spend over 
$8,000 per person this year for health care, 16 percent of New 
Jerseyans lacked insurance in 2007 and family insurance premiums are 
projected to rise from $14,000 in 2009 to $24,000 in 2019. In a country 
where we are projected to spend 18 percent of our Gross Domestic 
Product ($2.6 trillion) this year on health care, we can do better.
  The Affordable Health Care for America Act would improve the American 
health care system for all Americans, regardless of how they currently 
receive their health coverage. First, the legislation would lead to 
stable health costs that do not threaten family finances by 
establishing consumer protections for those purchasing private 
insurance. The bill would eliminate insurance benefit caps to ensure 
families do not have to worry about leaving the hospital with bills too 
big to pay because their benefits have run out. The bill would set an 
annual cap on out-of-pocket health expenses to eliminate cases where 
one disease forces a family into bankruptcy.
  Second, the bill would provide stable coverage for those between jobs 
or the self-employed by creating an insurance marketplace, where they 
could get insurance at group rates. Most of the policies in this 
insurance marketplace would be private insurance, while one of the 
plans would be a non-profit public plan. This public plan would be 
subject to the same requirements and regulations as the for-profit 
plans in the marketplace. The public option would be just that--an 
option in which no one would be forced to enroll. The bill also would 
eliminate the practice where patients with a pre-existing condition 
like diabetes or cancer or pregnancy cannot purchase insurance. 
According to a Congressional committee report, the bill would help 
10,000 uninsured individuals in Central New Jersey gain access to 
affordable health insurance.
  Third, the bill would strengthen Medicare by starting to pay 
physicians for treating the whole patient and by encouraging doctors to 
coordinate a patient's medical care instead of paying for each test or 
procedure. The legislation would strengthen the long-term health of the 
Medicare trust fund by increasing the efficiency of the program, 
expanding its ability to fight waste, fraud, and abuse, and eliminating 
wasteful subsidies to private insurance companies.
  It is worth repeating: not only would Medicare remain intact under 
this legislation, it would become better. The legislation would 
strengthen the Medicare trust fund by increasing the efficiency of the 
program, expanding its ability to fight waste, fraud, and abuse, and 
eliminating wasteful subsidies to private insurance companies. No 
standard Medicare benefits would be cut. In fact, Medicare would be 
improved by eliminating the ``doughnut hole'' in the prescription drug 
benefit. Each year in Central New Jersey, 8,300 seniors face the 
Medicare ``doughnut hole'' and are forced to pay their full drug costs, 
despite paying for Part D drug coverage every month. H.R. 3962 would 
provide these seniors with immediate relief by cutting brand name drug 
costs in the ``doughnut hole'' by 50 percent and ultimately eliminating 
the ``doughnut hole'' altogether. Further, the legislation would help 
seniors by eliminating co-payments and deductibles in Medicare for 
preventative services to ensure that diseases would be treated at their 
earliest stages and to keep seniors well. The legislation creates new 
Medicare incentives to encourage physicians and hospitals to coordinate 
medical care and seek to reduce duplicate tests, x-rays, and labs. 
These and other provisions are why AARP, among several others, has 
endorsed this health care reform legislation.
  This bill was created from one of the most open and deliberative 
processes in recent memory. During the past few years, Congressional 
committees held more than 53 committee hearings, debated and voted on 
almost 240 amendments, and considered health reform for 167 hours. Many 
of the amendments reflected concerns raised by constituents and have 
improved this bill further.
  While there are strong humane and moral reasons to pass this health 
reform bill, the economic reasons are equally strong. Businesses, large 
and small, feel a heavy weight in trying to afford health care for 
their employees--hurting the economy and costing jobs. Any family, 
regardless of their income, can find themselves in bankruptcy from one 
accident or expensive illness. All of this would change under this 
reform bill. The bill would lower health costs for families by 
increasing competition across all states through a new marketplace and 
eliminating the antitrust exemption. It would reduce costs by promoting 
coordinated medical care to eliminate duplicative tests, by simplifying 
insurance paperwork and electronic records. The bill would decrease 
costs by expanding research on which treatments work best for different 
patients, helping physicians and nurses provide effective medical care. 
Long term, the legislation would limit costs by shifting to a focus on 
health outcomes and rewarding physicians for treating the whole 
patient.
  It would do all this without adding one penny to the debt. Instead, 
it will lower the debt and, according to the Congressional Budget 
Office (CBO), produce a $109 billion surplus over a decade. We cannot 
afford not to pass health care reform and reduce the crippling health 
costs facing our nation, our businesses, and our families.
  Sadly, there is a great deal of misinformation about the proposed 
health reform bill. I have heard from some the myth that Members of 
Congress would be exempt from health care reform. It is worth noting 
that Members of Congress receive their health insurance like any other 
of the eight million federal employees and we pay premiums just like 
any other

[[Page 27476]]

worker. The health insurance reform bill includes several improvements 
to the overall insurance marketplace, all of which would apply to the 
federal employee health insurance plans. I welcome the fact that the 
reform legislation would apply to Members of Congress, just like 
employees of other large companies.
  Opponents of reform also claim that the House health reform bill 
would encourage euthanasia or insert the government into end-of-life 
conversations between patients and their physician. This claim is 
false. The truth is that the legislation would provide doctors with 
better payment for talking with their patients. This bi-partisan 
provision would provide payment for a doctor's time if a patient 
chooses to have a conversation about the care that the patient prefers 
if he or she becomes very ill, but it does not require anyone to use 
this benefit. These conversations would not involve any government 
employee, but would be solely between the patient and his or her 
physician. As noted by the AARP, ``[t]his measure would not only help 
people make the best decisions for themselves but also better ensure 
that their wishes are followed.''
  There is no reasonable basis for concern that seniors' conversations 
with their doctors on personal requests for end-of-life care would do 
anything to promote assisted suicide, which is illegal in New Jersey 
and 47 other states, or euthanasia, which is illegal in all states.
  Discussions between the sick or the elderly and their doctors about 
end-of-life care have long been an accepted part of modern patient care 
as a way to ensure that the patient's wishes are carried out. In 2003, 
under the Bush administration, the Agency for Healthcare Research and 
Quality issued a report outlining a five-part process for physicians to 
discuss end-of-life care with their patients. Unfortunately, doctors 
are not paid for such discussions and thus are not encouraged to have 
them. According to the National Hospice and Palliative Care 
Organization, which supports this provision, the bill simply would 
allow for counseling on decisions that require time and consideration.
  Another myth is that health reform would provide federal benefits for 
undocumented aliens. Undocumented immigrants currently may not receive 
any federal benefits except in specific emergency medical situations. 
There are no provisions in the House health reform bill that would 
change this policy. In fact, the legislation explicitly states that 
federal funds for insurance would not be available to any individual 
who is not lawfully present in the United States.
  I have heard from many constituents concerned about the inclusion or 
exclusion of family planning services in health insurance reform. The 
legislation would exclude federal funding of abortion, and maintain 
existing federal laws protecting conscience rights in health care. In 
fact, the amendment adopted tonight, which I believe is in error, would 
go further than existing law and even prevent women from using their 
personal funds from purchasing coverage for family planning services. I 
hope the conferees will revisit this issue to ensure women have the 
freedom to purchase the policy that best serves their needs and 
conscience.
  I am pleased that health reform will help small businesses. According 
to a report issued from the Council of Economic Advisors in July 2009, 
the current health care system places a heavy burden on small 
businesses through high premiums, fixed administrative costs, adverse 
selection, and comparative disadvantage with larger businesses in 
America and with businesses in other countries. This is why small 
businesses pay up to 18 percent more per worker for the same health 
insurance plan than a large firm. The House legislation would help 
small business employees purchase insurance at group rates through an 
insurance marketplace, and by providing a tax credit to help small 
businesses that purchase insurance. Almost 18,000 small businesses in 
Central New Jersey would receive this tax credit.
  The bill further recognizes the constraints facing small businesses 
and exempts many small employers from the shared responsibility 
requirement to provide insurance for their employees. The Congressional 
Budget Office and respected Massachusetts Institute of Technology 
health care economist Jonathan Gruber have pointed out that for the 
large majority of small businesses, the reform legislation would be a 
great improvement and would provide real savings.
  For years, small businesses have asked me and other Members of 
Congress to allow them to get better rates by pooling their employees 
in large numbers, which is currently available to only larger 
companies. The newly-created marketplace would allow insurance plans to 
pool the health risks of millions of people and thus get lower rates. 
In addition to the marketplace for small businesses created by the 
House health reform bill, I worked with my colleagues Rep. Phil Hare 
(D-IL) and Rep. Rob Andrews (D-NJ) to include language in this 
legislation that would allow affiliated small businesses to join 
together to purchase insurance. This proposal for helping small 
businesses was brought to me by a small businessman in my district.
  I also was pleased to write a section of the bill that would create 
an online job training programs for health care workers, modeled after 
a successful program originating at Rutgers University. This program is 
needed to help meet the increasing need for health care workers, which 
was indicated by a July report by the Council on Economic Advisors. The 
demand for health workers soon will exceed the supply with 48 percent 
growth in health support occupations such as medical record, clinical 
laboratory, and health information technicians. My amendment, included 
in H.R. 3962, would provide new training opportunities to meet this 
additional demand for health professionals.
  While I support the Affordable Health Care for America Act, I look 
forward to working with my colleagues to improve this bill as the 
legislative process moves forward. I have heard from home care and 
hospice providers in my district and across New Jersey who are 
concerned about the reductions in Medicare home health payments. I have 
spent time with home care organizations and with individual patients at 
home and have gained a deep understanding of the challenges and 
successes that occur each day. I fear that additional cuts to home 
health would make it harder to do the essential job that home care and 
hospice workers perform each day. I also am concerned that several 
provisions of the bill may impede biomedical research and innovation, 
as this research has improved patient care and fostered a successful 
life sciences industry in New Jersey.
  While the bill we are considering is strong, I know this bill will 
continue to improve as we move through the legislative process. Today's 
vote in the House of Representatives marks an important step in this 
process and is the furthest we have come toward providing affordable 
and quality health coverage to all Americans. I look forward to working 
to the completion of meaningful health care reform legislation and 
sending it to the President for his signature.
  I urge my colleagues to vote in favor of this bill to reform our 
nation's health insurance system.
  Mr. KLINE of Minnesota. Mr. Speaker, before I recognize the gentleman 
from California, I yield myself such time as I may consume.
  There has been quite a bit of discussion here about how this bill is 
going to help small businesses and reduce their taxes. I think it is no 
accident that business group after business group, small business after 
small business, large business after large business across this country 
is opposing this legislation. It is the businesses who are going to 
bear the first brunt of the taxes, bear the costs, and that is going to 
be relayed to lost jobs.
  For example, I have a whole list of organizations: the Associated 
Builders and Contractors; the Associated General Contractors; the 
International Franchise Association; the National Association of 
Manufacturers; the National Federation of Independent Businesses; the 
U.S. Chamber of Commerce; and on and on, oppose this bill because it 
does not help business. It puts a burden on them.
  Now I am pleased to yield 1 minute to the gentleman from California 
(Mr. McClintock).
  Mr. McCLINTOCK. Mr. Speaker, the question before us comes to this: 
Will Congress force American families to surrender control of their 
health care to the Federal bureaucracy? There is nothing optional about 
this law. The word ``shall'' appears 3,400 times in it, each time 
backed with the full force of the government.
  You shall only get your health care through the government exchange.
  You shall only select among the health care plans that the government 
czar has approved for you, whether they fit your family's needs or not.
  You shall buy a government-approved plan and pay for every 
government-imposed mandate in it through higher premiums, lower wages 
or higher taxes, and you will face steep fines and even Federal prison 
if you decline to do so.
  You ``shall'' 3,400 times.
  Whenever such a system is imposed, the result is always the same: 
massive cost overruns, followed by a brutal rationing of care.

[[Page 27477]]

  Instead of destroying everything that is good about American health, 
shouldn't we first repair what is wrong? Primum non nocere--first, do 
no harm.
  Mr. ANDREWS. I am honored to yield 1 minute to a gentleman who has 
done an extraordinarily effective job of representing his constituents, 
the gentleman from the Commonwealth of the Northern Mariana Islands 
(Mr. Sablan).
  Mr. SABLAN. Mr. Speaker, I rise today in support of H.R. 3962, the 
Affordable Health Care for America Act. The need for health care reform 
has never been greater nor more urgent. This is true for my district, 
as it is for our Nation. We cannot wait another day. We must seize the 
moment and pass a law that will go a long way toward providing quality, 
accessible, and affordable health care for all Americans.
  I urge my colleagues to support the bill.
  Mr. KLINE of Minnesota. Mr. Speaker, I would like to yield 2 minutes 
to another physician, a member of the committee who is not only a 
doctor, but a small businessman, the gentleman from Tennessee (Dr. 
Roe).
  Mr. ROE of Tennessee. Mr. Speaker, I thank the gentleman for 
yielding.
  I rise in opposition to this bill before us. I came to Congress to 
enact health care reform. As a physician, I have seen firsthand the 
problems insurance companies created for my patients. I have seen 
firsthand how the government programs have made beneficiaries worse 
consumers of health care, and I have seen how the cost of health care 
has exploded and made insurance unaffordable. I want to fix these 
problems. But this bill will not fix these problems; it will make them 
worse.
  The Democrats have ignored evidence that this program won't work. I 
asked President Obama three separate times since July to sit down and 
talk about the health care bill and what I know its effects will be, 
and I have yet to receive a call from the White House. It is one thing 
to disagree with the evidence that undermines the premise of reform you 
are pushing, but to not even consider it is unbelievable.
  So here we are today with a health care bill that is over 2,000 
pages. It is a Christmas tree of special interests. Sewer systems for 
Indian tribes, biofuel tax credits, nutrition standards for chain 
restaurants, and references to pizza and donuts all made it into this 
bill. But somehow the Democrats could not come up with a real solution 
for medical malpractice reform.
  This bill taxes everyone and everything. It taxes medical devices, it 
taxes individuals, it taxes employers. It taxes small business owners 
who could be creating jobs and getting us out of this recession, 
instead forcing them to cut wages for jobs. It taxes medical savings 
accounts. It cuts Medicare. Home health care, skilled nursing 
facilities and Medicare Advantage would all be cut. And seniors with 
prescription drug coverage will have their premiums increased. Seniors 
oppose this bill because they get it. Their care is going to decrease 
and their costs are going up.
  The bill spends all that money even faster. The bill dramatically 
expands Medicaid, despite the fact that I haven't heard anyone who had 
an option say they want to be on Medicaid. It creates a huge new 
Federal bureaucracy to navigate through. And it funds a government 
competitor to private insurance companies that will siphon people off 
the private insurance market onto a Medicaid-like program, just like 
Tennessee did with Tenncare.
  Mr. Speaker, I came to Congress to enact health care reform. As a 
physician, I've seen firsthand the problems insurance companies created 
for patients. I've seen firsthand how government programs have made 
beneficiaries worse consumers of health care. I've seen how the cost of 
health care has exploded, so much so that many can't afford insurance. 
I've seen all these problems and I want to fix them.
  When I first heard that the Democrats were proposing to insert a 
government competitor in the insurance marketplace, I thought, surely 
they can't be serious. When I realized they were, I thought I could 
change their opinions by telling them about the real-life failures I've 
seen under our state's program known as TennCare and how H.R. 3200 and 
now 3962 is simply a bad extension of these mistakes.
  For months I've gone to the House floor with many of my physician 
colleagues to talk about the problems with this plan. The TennCare plan 
tried to provide universal coverage and make health insurance 
affordable, and in the end it nearly bankrupted the state as the 
program tripled in cost. It created an incentive for beneficiaries to 
seek unnecessary care because it cost them nothing. It shifted costs to 
the private plans, who were forced to make up the underpayments of the 
government program, increasing everyone's premiums. In the end, 45 
percent of those on the public plan previously had private insurance 
and either dropped their coverage or were dropped by their employer.
  Our Democratic Governor, Phil Bredesen, saved our state's budget by 
doing something hard--he cut the rolls. He controlled costs and he 
introduced an alternative plan called Cover Tennessee, which requires 
an equal contribution from employers, individuals and the government, 
which is a model for shared responsibility. Incidentally, Governor 
Bredesen has called this bill on the floor the mother of all unfunded 
mandates.
  Democrats continued to ignore this evidence. I asked President Obama 
three separate times since July to sit down and talk about the health 
care bill and what I know its effects will be, and I have yet to 
receive a call from the White House. It's one thing to disagree with 
evidence that undermines the premise of the reform you're pushing, but 
to not even consider it is unbelievable.
  So here we are today with a health care bill that is over two 
thousand pages. It's loaded up like a Christmas tree of special 
interest provisions. Sanitation facilities for Indian tribes, biofuel 
tax credits, nutrition standards for chain restaurants, and references 
to pizza and doughnuts all made it into this bill, but somehow, 
Democrats could not come up with a real solution for medical 
malpractice reform except to try to protect trial lawyers' share of 
jury awards. Malpractice is proven to cost the health care system 
billions of dollars every year, but the reforms being proposed make the 
current system worse.
  This bill taxes everyone and everything. It taxes medical devices. It 
taxes individuals who choose not to purchase insurance, and drives up 
premiums for individuals who do purchase insurance. It taxes employers 
who fail to offer health insurance, then taxes them further if they try 
to increase their employees' wages. It taxes small business owners, who 
could be creating jobs and getting us out of the recession, and instead 
forces them to cut jobs or wages. It taxes health savings accounts, 
which reduces the use of catastrophic health insurance coverage.
  It cuts Medicare. Home health care, skilled nursing facilities and 
Medicare Advantage would all be cut, and seniors with prescription drug 
coverage will have their premiums increased. Seniors oppose this bill 
because they get it--their care is going to be decreased and costs are 
going up.
  After the bill finishes up taxing everything and everyone, it spends 
all that money even faster. The bill dramatically expands Medicaid, 
despite the fact that I've never heard of anyone saying they want 
access to the program. It creates a huge new federal bureaucracy to 
navigate through. And it funds a government competitor to private 
insurance companies that will siphon people off of private insurance 
onto a Medicaid-like program, just like Tennessee did with TennCare.
  After the Democrats finish spending $1.5 trillion, they say the bill 
is quote unquote deficit neutral. But they ignore that every major 
government health care expansion before it--Medicare, Medicaid, SCHIP 
to name a few--have cost more than originally estimated. And they 
completely ignore the fact that they use 10 years of revenue to pay for 
7 years of new spending. In the second decade, this program will become 
an enormous unfunded mandate on state governments, on individuals and 
on the federal government. Despite the largest deficit in our nation's 
history, the Democrats are irresponsibly going to make it harder to 
ever balance the budget.
  Here's the bottom line: this bill costs too much. It taxes too much. 
It does nothing to improve health care, and will result in the majority 
of Americans left with decreased access, decreased quality and 
increased costs. It is, as the Wall Street Journal called it, the worst 
bill ever and deserves to be rejected.

                              {time}  1900

  Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1 minute to the 
gentlewoman from New York (Ms. Clarke), one of the leading voices for 
senior citizens, resulting in the AARP endorsing our bill.

[[Page 27478]]


  Ms. CLARKE. I thank the gentleman from New Jersey very much.
  Mr. Speaker, today I rise to support H.R. 3962, the Affordable Health 
Care for America Act. As we approach the dawning of the second decade 
of the new millennium, this evening we will usher in a new assurance of 
the health and well-being of all Americans. Our children will have the 
health and peace of mind to exceed the productivity of our generation. 
Our willingness to do what it takes to transition into the 21st century 
health care delivery system will guarantee future generations the 
advancement of a productive civil society.
  Every American has a right to adequate physical and mental health 
care, and I believe that we, as a national government, have a 
responsibility to assist our citizenry in securing quality health care. 
It is unfortunate that there are those amongst us who just couldn't 
care less; those who were satisfied with the status quo of rising 
premiums, satisfied with individuals being denied coverage because of 
preexisting conditions, satisfied with ignoring the pain and suffering 
of the 47 million Americans who are uninsured.
  Mr. Speaker, I urge all of my colleagues to vote for this measure.
   Mr. Speaker, today, I rise in support of H.R. 3962, Affordable 
Healthcare for America Act. This evening, as we approach the dawning of 
the second decade of the new millennium, we will usher in a new 
assurance of the health and well being of all Americans. Our children 
will have the health and peace of mind to exceed the productivity of 
our generation. Our willingness to do what it takes to transition to a 
21st century healthcare delivery system will guarantee future 
generations the advancement of a productive civil society.
  In the United States, one of the richest countries in the world, 
nearly 47 million Americans lack health insurance, 13.5 percent of whom 
are New Yorkers. Last year alone, New York City's hospitals spent $1.2 
billion in charity costs. Tragically, people who are either uninsured 
or underinsured often have to go without vital healthcare simply 
because they cannot afford it.
  Every American has a human right to adequate physical and mental 
healthcare, and I believe that we as a national government have a 
responsibility to assist our citizens in securing quality healthcare.
  Unfortunately, my Republican colleagues don't seem to fully grasp the 
dire situation our healthcare system is in. Maybe they would have come 
up with a bill that actually addressed the deficiency in our broken 
healthcare.
  It is unfortunate that there are those amongst us who just could care 
less--those who are satisfied with the status quo of rising premiums, 
satisfied with individuals being denied coverage because of pre-
existing conditions, satisfied with ignoring the pain and suffering of 
the 47 million Americans who are uninsured.
  Instead of working with us to fix the problem, they capitalize on 
people's fears and doubts. It is meant to distract, delay, confuse, and 
engender fear among our citizens. Today we will not allow the voices of 
fear to dominate the healthcare reform debate.
  This bill provides healthcare coverage to 96 percent of Americans and 
includes a strong public option that will provide the needed 
competition to lower premium costs. That is why I support H.R. 3962, 
Affordable Healthcare for America Act.
  With preventative care as the cornerstone of the 21st century 
healthcare delivery system, eliminating the disparate treatment of 
women, eliminating discrimination based on pre-existing conditions, 
creates a new health exchange for access to quality affordable health 
insurance and turns medical visits from a broken volume based system to 
a 21st century value based system. I will cast my vote this evening in 
memory of a distinguished New Yorker, Brooklynite and friend Jackie 
Ward, who died of heart failure as a young woman in her early 50s.
  In my district, the 11th Congressional District of Brooklyn, the 
Affordable Healthcare for America Act will: First, improve employer-
based coverage for 367,000 residents. As a result of the insurance 
reforms in the bill, there will be no co-pays or deductibles for 
preventative care; no more rate increases or coverage denials for pre-
existing conditions, gender, or occupation; and guaranteed oral, 
vision, and hearing benefits for children. Second, it will provide 
credits to help pay for coverage for up to 160,000 households, if they 
need to purchase their own coverage. Third, under the bill's insurance 
reforms, 11,900 individuals in the district who have pre-existing 
medical conditions will now be able to purchase affordable coverage. 
Finally, this bill will allow 11,300 small businesses to obtain 
affordable healthcare coverage and provide tax credits to help reduce 
health insurance costs for up to 11,400 small businesses.
  Healthcare is a fundamental human right, rather than a commodity. A 
year ago, Americans cast a historic vote to change the course of this 
Nation. Today, we cast this historic vote, to finally manifest the 
change they demanded: Access to Affordable Healthcare. I am proud to 
cast my vote in favor of this bill.
  Mr. KLINE of Minnesota. Mr. Speaker, may I inquire as to the time 
remaining on each side?
  The SPEAKER pro tempore. The gentleman from Minnesota has 16 minutes. 
The gentleman from New Jersey has 14 minutes.
  Mr. KLINE of Minnesota. Thank you, Mr. Speaker.
  At this time I am pleased to yield 1 minute to the gentleman from 
Pennsylvania (Mr. Thompson), a member of the committee.
  Mr. THOMPSON of Pennsylvania. Mr. Speaker, I rise today in opposition 
to H.R. 3962. I came to Congress this past January following 28 years 
in nonprofit health care. In January, the Democratic majority quickly 
moved the SCHIP reauthorization. I supported the final passage of the 
bill. SCHIP was modeled after Pennsylvania's CHIP program, a bipartisan 
public-private partnership to offer private insurance to my State's 
most vulnerable population. CHIP works in Pennsylvania.
  Mr. Speaker, I am dismayed to learn that this bill will scrap the 
SCHIP program. This will jeopardize coverage and increase costs for 
scores of Pennsylvania's needy children. Families who rely on 
Pennsylvania's CHIP program will faces higher costs when their children 
are forced into plans offered through the exchange. We have heard from 
my colleagues about cuts to our seniors, small businesses, family 
farms, and agriculture. Now you are hearing about the cost to our 
children.
  As a health professional, I urge my colleagues to vote ``no'' on this 
measure, and I would like to submit a letter from five of my Republican 
colleagues from Pennsylvania on this issue.

                                 Congress of the United States

                                 Washington, DC, November 7, 2009.
     Hon. Nancy Pelosi,
     Speaker, House of Representatives, The Capitol, Washington, 
         DC.
       Dear Speaker Pelosi: We are writing to express our grave 
     concerns with provisions included in H.R. 3962, the 
     Affordable Health Care for America Act, that would eliminate 
     the Children's Health Insurance Program (CHIP) and require 
     all children above 150 percent of the federal poverty level 
     (FPL) who are not covered under a Medicaid CHIP (M-CHIP) 
     expansion program to be moved into the new health insurance 
     exchange. These extremely troubling provisions will add an 
     undue cost burden on children and families in Pennsylvania as 
     well as delays in care and coverage gaps when CHIP plans are 
     terminated.
       Members of the Pennsylvania General Assembly strongly 
     advocated for the creation of Pennsylvania's CHIP law in 
     1992, and improvements to the program in 1997. Our program 
     served as a model for the federal CHIP law, and it has been 
     an overwhelming success in our state. There is no better 
     example of a public-private health partnership that has 
     contributed to the lives of Pennsylvania families. We often 
     hear from our constituents that their children are healthy 
     and active because of CHIP.
       Now, only months after you championed for the 
     reauthorization of CHIP, it is surprising that the bill you 
     are ushering through the House is proposing to eliminate this 
     successful program. These provisions would jeopardize 
     coverage and increase costs for scores of Pennsylvania's 
     children since Pennsylvania operates CHIP as a separate 
     program and makes coverage available to children beyond 150 
     percent of FPL.
       A recent actuarial analysis demonstrates that CHIP benefits 
     are superior for low-income families than the House health 
     care legislation. Families who rely on Pennsylvania's CHIP 
     program will face higher costs when their children are forced 
     into the plans offered through the exchange. For instance, 
     for children living in families earning 175 percent of FPL, 
     the study finds that the median CHIP plan covers 100 percent 
     of medical expenses covered by CHIP. Under the House bill, 
     that family will pay nearly 400 dollars. For children in 
     families earning 225 percent of FPL the median CHIP plan 
     covers 98 percent of medical expenses, exposing children to 
     only 2 percent of costs. Comparable exchange plans would 
     expose families to 5 percent to 35 percent of out-of pocket 
     costs.
       We have witnessed first hand that CHIP is an efficient 
     program that provides Pennsylvania children with affordable, 
     quality care.

[[Page 27479]]

     H.R. 3962 is a step in the wrong direction for our children--
     imposing higher costs and delivering fewer benefits to our 
     most vulnerable population.
       For several additional reasons, we will vote against H.R. 
     3962. Protecting children, especially those most in need, 
     should be one of Congress's top priorities in the context of 
     health care reform. We urge you to reconsider the direction 
     H.R. 3962 will lead this country and the consequences of 
     eliminating CHIP for Pennsylvania's children.
           Sincerely,
     Charles W. Dent,
       Member of Congress.
     Todd Russell Platts,
       Member of Congress.
     Bill Shuster,
       Member of Congress.
     Jim Gerlach,
       Member of Congress.
     Glenn Thompson,
       Member of Congress.

  Mr. ANDREWS. Mr. Speaker, I yield myself 3 minutes.
  I would like to thank my friends on both sides of the aisle. This has 
been a stressful time for Americans, and today may have been a very 
stressful day for Americans.
  This might have been the day that someone thought they were going to 
get a job but found out that they won't get the job because they had 
breast cancer 5 years ago and can't get health insurance because of 
their preexisting condition. It has not been their day.
  Or it might be the day that a senior citizen decides that they don't 
have the money this week to renew their prescription because they're in 
the doughnut hole under Medicare. So they're going to pay their rent 
instead of their prescription bill, and they're going to get very sick. 
It's just not their day.
  Or it might be the day that someone is lying awake in bed, churning 
about the fact that their child seems a little sicker than usual. But 
if they take them to the doctor, they might get sent to the hospital, 
and they can't pay the hospital bill because they have no health 
insurance, and it might mean bankruptcy or foreclosure or losing their 
home. It's just not their day.
  If we pass this bill and it gets to the President's desk, a new day 
will come to this country, because no person with a preexisting 
condition will ever suffer discrimination again; because effective next 
year, eventually no senior will run out of drug coverage at any time 
during the year because they work for it and they deserve it. The new 
day will come to that uninsured person because no hardworking American 
will ever go without health insurance in this country.
  You know, the special interests and the lobbyists and the health 
insurance industry, they have all had their day. They have been around 
here for a very long time. And I hate to disappoint them, but today is 
not their day. It is the day for uninsured Americans. It is the day for 
hardworking Americans. This is the day when we will begin the change, 
and every American will get the health care they so richly deserve.
  Stand up for those who cannot be heard, and vote ``yes'' for this 
bill.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield 2 minutes to the 
gentleman from Michigan (Mr. Ehlers), a member of the committee.
  Mr. EHLERS. Mr. Speaker, I certainly support making health care more 
affordable and accessible for all Americans. Perhaps I'm naive, but I 
had hoped that we would have been able to produce a bipartisan bill 
that I could gladly vote for. Such is not the case. We were not even 
given the courtesy by the other party of taking part in writing this 
bill and presenting ideas which could be included in the bill.
  The status quo in the health care system is unacceptable. We must 
make health care more affordable and accessible than it is. But this 
bill is even less acceptable than the current health care system. This 
bill will result in large tax increases, as we've heard, which is 
absolutely the last thing that my State of Michigan needs because we 
are struggling so hard with the economy the way it is. This proposed 
bill is basically a government takeover.
  What am I looking for? I'm looking for health care quality. That, to 
me, means getting the treatment you need, when you need it, from the 
doctor you choose. This bill does nothing to provide that.
  Time is a great health care killer among governments. We looked at 
other countries. They may have very good plans, but if you need an MRI 
today and you have to wait for 6 months, you are not getting good 
health care. We want to make sure that the plan we develop provides the 
health care you need, when you need it, from the doctor you choose.
  I truly hope that, in the future, as we go through the conference 
process with the Senate, that our Republican ideas will be incorporated 
as well as the Democratic ideas, and that we really produce the best 
bill we can. We did that with Medicare. We tried to do it with Medicare 
part D, and I would hope that the Democratic Party, instead of just 
glorying in their bill, and doing their own thing, and ignoring the 
Republicans, would, in fact, work with us and try to produce a bill 
that is good for the country, for the people, and especially for those 
who need medical care.
  The SPEAKER pro tempore. Without objection, the gentleman from 
California (Mr. George Miller) will control the remainder of the time.
  There was no objection.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Ohio (Mr. Wilson).
  Mr. WILSON of Ohio. Mr. Speaker, as we wind down the clock on the 
health care debate, I have thought long and hard about what's best for 
my district back in Ohio, and I have concluded that the Affordable 
Health Care for America Act is an important step forward in fixing our 
broken health care system.
  While this legislation is not perfect, there are benefits that are 
simply too hard to ignore. For example, in my district, 13,000 small 
businesses will have the opportunity to provide their employees better 
health care. We will close the drug doughnut hole for over 9,000 
seniors just in my district alone, and it will help 174,000 households 
in the Sixth Congressional District afford better coverage.
  I have always promised the people that I work for back home that I 
will vote in their best interest and that I will stand up for what is 
right. I am proud to be here this evening on this issue, and I believe 
that this bill is the right thing to do to provide stability and 
security for the families in Ohio in my district.
  Mr. KLINE of Minnesota. Mr. Speaker, I am pleased to yield 1 minute 
to my colleague, the gentlewoman from my home State of Minnesota (Mrs. 
Bachmann).
  Mrs. BACHMANN. Mr. Speaker, the American people overwhelmingly reject 
the government takeover of our health care. Last Friday, a couple from 
Hawaii decided the time is so short they needed to get on a plane, come 
to Washington to beg their Representative to vote ``no'' from Hawaii. 
What sacrifices freedom-loving Americans are making to get their 
government's attention and how big our government has gotten.
  They brought me this beautiful, precious lei, and I am reminded that 
the one who created this lei also created our freedom. Are we so 
insensible to the high cost our forebears paid to purchase our freedom? 
Tonight, would we foolishly bargain those freedoms away? The American 
people, our forebears, generations yet unborn, are crying out to us 
tonight for us to preserve their freedoms.
  Vote ``no'' on the government takeover of health care.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentlewoman 
from Pennsylvania (Mrs. Dahlkemper).
  Mrs. DAHLKEMPER. Mr. Speaker, the American people overwhelmingly have 
called on us, their Representatives, to enact real change in our 
country and in their lives. The Affordable Health Care for America Act 
embodies the positive change the American people have demanded.
  This bill creates effective, affordable, and quality reform for all 
Americans. Seniors will benefit from a stronger Medicare system, no 
longer subject to the prescription drug doughnut hole or have to pay 
out of pocket for their primary care needs. Small businesses will no 
longer be burdened by skyrocketing health care costs. Tax credits and

[[Page 27480]]

greater competition in the health care market will make coverage 
affordable for these small businesses, and no individual will ever 
again be denied health insurance because of preexisting or chronic 
conditions.
  My colleagues, the need for reform is clear, and the time for reform 
is now. I urge Members on both sides of the aisle to vote for the 
Affordable Health Care for America Act for our seniors, for all women, 
for small businesses, and mostly for our precious children and 
grandchildren.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time, I yield 1 minute 
to the gentleman from Texas (Mr. Smith), the ranking member of the 
Judiciary Committee.
  Mr. SMITH of Texas. Mr. Speaker, I thank the gentleman from 
Minnesota, the ranking member of the committee, for yielding me time.
  According to CBO estimates, this bill will cost $1.3 trillion and 
includes $750 billion in new taxes and $500 billion in Medicare cuts. 
It increases premiums, increases taxes, cuts benefits, and leads to 
health care rationing. The government, rather than patients and 
doctors, will make many health care decisions. The bill represents a 
loss of freedom and more government control for the American people.
  I support health care reform to help the long-term, low-income 
uninsured, but it can be achieved without a government takeover of 
health care. The House Republicans have a better health care bill that 
lowers premiums for families and small business owners, cuts the 
deficit by $68 billion, and includes tort reform.
  Mr. GEORGE MILLER of California. If I could inquire of the Chair as 
to how much time is remaining on both sides.
  The SPEAKER pro tempore. The gentleman from California has 10 
minutes. The gentleman from Minnesota has 11 minutes.
  Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman 
from Missouri (Mr. Carnahan).
  Mr. CARNAHAN. Mr. Speaker, ``millions do not now have protection or 
security against the economic effects of sickness. The time has arrived 
for action to help them attain that opportunity and that protection.'' 
President Truman delivered these words in a special message to Congress 
in 1945, calling for comprehensive health care in America.
  Health care in America has been broken far too long, unavailable and 
unfair for too many, becoming more unaffordable every year. Health care 
premiums have doubled in 10 years. Health care bills are the number one 
reason for personal bankruptcies in our country. Health care costs are 
the number one contributor to our deficit. We spend more on health care 
than any other country, yet we rank near the bottom in terms of health 
care results.
  This bill builds upon the best parts of our private employer-based 
system and fixes what's broken to lower costs, increase competition, 
promote preventive medicine, and protect seniors. Many ideas and 
concerns from Missourians I represent have been included in this bill 
to make it even better. History and the American people are calling us 
to action. The time is now to fix health care in America.
  Mr. KLINE of Minnesota. Mr. Speaker, now I yield 1 minute to the 
gentleman from Alabama (Mr. Aderholt).

                              {time}  1915

  Mr. ADERHOLT. Mr. Speaker, there is no question we need to address 
health care problems in this Nation. That is something both Democrats 
and Republicans both agree on.
  However, the government takeover of health care that we are debating 
tonight adds up to way too much spending, too much government 
bureaucracy, too many unfair mandates, too much government control in 
an area with where government just doesn't belong.
  The Republican substitute is about to be debated tonight, and it will 
attempt to fix the broken aspects of health care in the United States. 
There will be many of us tonight in this Chamber who will vote ``yes'' 
on that Republican substitute because there needs to be changes. 
However, we will vote ``no'' on final passage because we don't want to 
throw the baby out with the bath water in order to fix the problems.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentleman from Michigan (Mr. Schauer).
  Mr. SCHAUER. Mr. Speaker, because of rising medical costs, families 
in America are literally going broke. Yes, broke. The American Journal 
of Medicine reported that 62 percent of American bankruptcies are 
linked to medical bills. These medical bankruptcies have increased by 
50 percent in just 6 years. The shocking fact is that 78 percent of 
these people actually had health insurance, but gaps and inadequacies 
in the current system left them unprotected when they were hit by 
devastating bills.
  Important insurance reforms in this bill will fix this, and as a 
result of this bill, 36,000 of my constituents will finally be able to 
afford quality health coverage and peace of mind for their families.
  Perhaps more than in any other State, people in Michigan know that 
the current system is broken. It's time for us to fix it. It's time for 
us to pass H.R. 3962.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to 
the gentleman from Indiana (Mr. Burton).
  Mr. BURTON of Indiana. I thank the gentleman for yielding.
  Government can't give until it takes. There is no such thing as a 
free lunch.
  You know, we have 10.2 percent unemployment right now. This bill is 
going to cost about 5.5 million jobs. It's going to cost $730 billion 
in new taxes and $1.2 trillion for the program over the next decade. We 
can't afford that at this time with unemployment being at the rate that 
it is.
  We face a $1.4 trillion deficit this year alone, and you're going to 
add $1.2 trillion to that and a $730 billion tax increase with 10.2 
percent unemployment?
  You're going to cost jobs. And the American people want jobs right 
now, first and foremost. Jobs. Jobs. Jobs. And then deal with some of 
these things in a more responsible way.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to our 
new Member from New York (Mr. Owens).
  Mr. OWENS. Mr. Speaker, my district needs one thing: jobs.
  In Upstate New York small businesses are the jobs engine. Over the 
past 15 years, they have been responsible for nearly two-thirds of all 
jobs created in America. But the cost of health care is grinding the 
engine down. Over the last decade, small business insurance premiums 
are up 129 percent. That means much higher expenses, more businesses 
dropping coverage, a sicker, more financially strapped workforce, and 
enormous pressure on small business owners from competitors overseas 
and big businesses at home.
  The bill can change that. It creates a competitive marketplace where 
individuals and small businesses can shop for policies at fair rates. 
It guarantees free preventative care for a healthier, more productive 
workforce. And it encourages Americans to start businesses of their own 
because the cost of health care will no longer tie them to the same 
job.
  The people of my district need jobs. They need me to vote ``yes.'' I 
came to Congress to move America forward. This will do that.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 3 minutes 
to the distinguished Republican leader, the gentleman from Ohio (Mr. 
Boehner).
  Mr. BOEHNER. I thank my colleague for yielding.
  For many of us on both sides of the aisle who believe in the sanctity 
of human life, the underlying bill allows for taxpayer funding of 
abortion. The Speaker has allowed Mr. Stupak and others to offer an 
amendment tonight.
  And, Mr. Miller, if that amendment were to pass and this bill were to 
get to conference and there were a vote in the conference on this, 
would you guarantee me that you would support the House-passed version?
  Mr. GEORGE MILLER of California. Will the gentleman yield?

[[Page 27481]]


  Mr. BOEHNER. I'm happy to yield.
  Mr. GEORGE MILLER of California. As he has already acknowledged, when 
he was Chair and he went to conference many times, he could not 
guarantee anything. You will take into this House, if that amendment 
should pass, that will be an expression of this House on that subject, 
on that amendment. We will take that with the full dignity of that vote 
into that conference committee.
  Mr. Boehner, if you can speak for the Senate--nobody else has been 
able to.
  Mr. BOEHNER. Reclaiming my time, the question was this: If the House 
is to pass the Stupak amendment and this bill is to pass tonight and 
there is a vote in the conference on this issue, would you guarantee me 
that you will support the House-passed version?
  Mr. GEORGE MILLER of California. I will not guarantee that. You know 
the nature of the conference committee.
  Mr. BOEHNER. Reclaiming my time, this is the third chairman tonight 
who will provide no guarantees that if the House were to pass the 
Stupak amendment that they would vote in committee to support the 
House-passed version.
  This is the point of why I've been down here making this an issue: 
just because we pass an amendment to help facilitate the passage of 
what I think is a bad bill does not mean that the language that this 
House votes on is committed to by the Democrat leaders in this House.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to our 
new Member to the Congress from California, Congressman Garamendi.
  Mr. GARAMENDI. Mr. Speaker, 3 days ago I had the great honor of 
joining this august body, which for more than a century has debated 
health care.
  Two hours ago a dear friend Chic Dambach and his adult son came to my 
office. At the age of 2, Kai's kidneys failed. Chic and his family had 
health insurance. Their insurance company refused to cover transplants. 
Chic and his wife, Kay, were faced with a choice: enormous personal 
debt or their son's life. They chose life.
  A decade of battles with their insurance company together with 
crushing debt, Kai, when he becomes 23, will be uninsurable. He has a 
preexisting condition.
  H.R. 3962 is America's opportunity to end this despicable situation. 
The bill has strong comprehensive insurance reform and creates the 
penultimate enforcement mechanism: the public option. Americans should 
not be at risk any longer. The bill deserves our support.
  Mr. Speaker, three days ago I had the great honor of joining this 
august body that for 220 years has debated the momentous issues of the 
day, wars, industrial and labor policy, civil rights, environmental 
protection, and social security, and for more than a century--health 
care policy.
  Today we are faced with a choice. Do we vote no health insurance 
reform and continue the current situation that has placed in jeopardy 
every person in America who is not yet 65 years of age? Or do we vote 
today to provide every American with a comprehensive, affordable, and 
available health care policy?
  One example of why we must vote yes on H.R. 3962 and end the health 
care crisis that millions of Americans face each year is Chic Dambach 
and his son Kai.
  Some of you may know Chic as the former President of the Returned 
Peace Corps Association. Chic and his family had a comprehensive family 
health insurance policy. At the age of two, Kai's kidneys failed.
  Their insurance company refused coverage for kidney transplants. Chic 
and his wife Kay were faced with a choice, more than a hundred thousand 
dollars of personal debt or their son's life. They chose life.
  Today, Kai is a freshman at the University of Maryland. More than a 
decade of battles with their insurance company has ensued together with 
a crushing burden of debt. When Kai becomes 23 he will be uninsurable. 
Like millions of other American's he has a preexisting condition.
  H.R. 3962 is America's opportunity to end this despicable situation. 
The bill has strong comprehensive insurance reform and creates the 
penultimate enforcement mechanism--The public option--that in its 
fullness would allow all of us to walk away from the clutches of the 
profit before people private insurance companies whose first operating 
commandment is ``Pay as little as late as possible.''
  This must end. Americans should not be at risk any longer. H.R. 3962 
is the solution. It deserves our support.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield for the purpose of 
making a unanimous consent request to the gentleman from Pennsylvania 
(Mr. Dent).
  Mr. DENT. Mr. Speaker, I rise in opposition to this government 
takeover bill.
  I have spent the past week reviewing the 1,990 page health-care 
bill--H.R. 3962--that was introduced last Thursday and the manager's 
amendment that was filed late Tuesday night. I oppose this legislation 
which will exacerbate rather than solve the problems in our health care 
system and take our Nation in the wrong direction.
  Although I believe health care reform is needed, diminishing 
Americans' control over their health care decisions, cutting Medicare 
benefits for seniors, eliminating SCHIP coverage for low-income 
children, imposing punitive taxes on small businesses and increasing 
health care costs for all Americans in order to create an unsustainable 
entitlement program that will bury our Nation in debt is not the way to 
do it. Fundamentally, this bill moves the United States in the 
direction of a European style welfare state which is accompanied by 
much higher European style tax rates, slower economic growth and 
structurally higher unemployment rates. The bottom line is that this 
legislation will lead to fewer opportunities for our children and 
grandchildren.
  H.R. 3962 is bad for Americans because it won't reduce health care 
costs--in fact many will see increased costs--and it will cause 
millions of working Americans to lose their current coverage.
  It's bad for seniors. The bill includes nearly a half-trillion 
dollars in cuts to Medicare benefits. It will mean less choices, as 
well as increased premiums and prescription drugs costs for thousands 
of seniors in the 15th District.
  It's bad for Pennsylvania's children, who will be forced out of the 
State's successful CHIP program into plans offered through the health 
insurance exchange where families will face higher costs.
  It's bad for Pennsylvania's already struggling budget, forcing an 
unfunded Medicaid mandate of at least $2.2 billion on our cash-strapped 
Commonwealth.
  It's bad for small businesses. It will stifle innovation and job 
creation by imposing punitive surtaxes. It's bad for the Pennsylvania 
economy in particular, with a $20 billion tax on the makers of medical 
devices, an industry that employs thousands in my district and the 
surrounding region.
  And above all it's bad for America, spending more than $1 trillion in 
taxpayer dollars to create an unsustainable new Federal program and 
saddling our children and grandchildren with debt. Only in Washington 
can someone say with a straight face that by creating a new trillion 
dollar program that we will not add a dime to the deficit now or in the 
future.
  If we are serious about enacting meaningful health care reform that 
will ensure that all Americans have access to quality care, we must 
address the issue of cost. American families are struggling to afford 
increasing health care costs and health care spending is taking up a 
larger and larger portion of Federal, State, and local governments' 
budgets.
  Regrettably, H.R. 3962 fails to address one of the key reforms that 
will save billions of dollars and reduce health care costs--medical 
liability reform. In fact, the provisions in H.R. 3962 will actually 
heighten the medical liability crisis facing our Nation.
  The medical justice system is one of the major drivers of cost in our 
health care system. Doctors practice defensive medicine--ordering tests 
and treatments that are not truly needed but prescribed to ward off 
frivolous lawsuits. We have all been in our doctor's office and 
thought, ``Do I really need this?'' This defensive medicine doesn't 
mean better care; it just means more expensive care. The litigious 
environment has caused medical liability insurance premiums to 
skyrocket. In turn, patients pay more for health care because the costs 
are passed down.
  The practice of defensive medicine costs the United States more than 
$100 billion per year--some studies have estimated the cost may be as 
high as $151 billion to $210 billion annually. In Pennsylvania, not 
only are medical liability insurance rates increasing costs for 
patients, they are driving qualified doctors out of the Commonwealth.
  Recently, the Congressional Budget Office, CBO, released an analysis 
indicating that medical liability reforms would save the government $54 
billion over 10 years and cut national healthcare spending by 0.5 
percent a

[[Page 27482]]

year. These savings would be the result of direct savings from lower 
premiums for medical liability insurance and also indirect savings from 
reduced utilization of health care services.
  The original House health care bill, H.R. 3200, was silent on medical 
liability reform. Just 3 of the 1,990 pages of H.R. 3962 address the 
issue. Tragically, the language in H.R. 3962 actually discourages 
States from making the medical liability reforms that CBO has said will 
save $54 billion. This is politics at its worst--protecting trial 
lawyers at the expense of patients.
  Yesterday, I offered an amendment to the Rules Committee that would 
have inserted significant medical liability reform provisions into H.R. 
3962. My amendment would enact nationwide reforms aimed at ending the 
costly practice of defensive medicine and encourage States to adopt 
effective alternative medical liability laws that will reduce the 
number of health care lawsuits initiated, reduce the average amount of 
time taken to resolve lawsuits and reduce the cost of malpractice 
insurance. Specifically, I believe we must stabilize compensation for 
injured patients, hold parties responsible for their degree of fault, 
ensure that meritorious claims are swiftly resolved, encourage 
compliance with accepted clinical practice guidelines, and guarantee 
that medical care is available to those who need it the most by 
providing protections to safety-net providers.
  Unfortunately the leadership in the U.S. House of Representatives 
made the choice to prohibit meaningful reform from being debated on the 
House floor today. I sincerely regret that the majority decided to 
bulldoze ahead without considering practical policy that will reduce 
costs and produce significant savings in our health care system.
  With common sense, bipartisan discussion, we can make straightforward 
reforms to our health care system that will address the most pressing 
problems. We can enact strong insurance market reforms that provide 
consumer protections and promote transparency. We can ensure that those 
with chronic conditions and preexisting conditions have coverage 
through high-risk pools and reinsurance models. We can actually lower 
the cost of health care and increase access to affordable coverage by 
removing restrictive barriers on competition across state lines, 
allowing businesses to pool together and get the same buying power as 
their larger competitors, equalizing tax treatment for individuals 
buying health insurance, and enacting meaningful medical liability 
reform. We can put our Nation on the path to a healthier future by 
focusing on prevention and wellness.
  Today, the House majority has failed the American people. Now the 
Senate has an opportunity to prevent this ill-conceived measure from 
moving forward, and embrace the calls of the American people to unite 
behind meaningful reforms that will reduce cost and increase access 
without fundamentally altering the American economy.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to 
the gentleman from Florida (Mr. Bilirakis).
  Mr. BILIRAKIS. Mr. Speaker, I rise today to oppose the Democrats' 
government takeover of health care.
  This bill will raise taxes on individuals and small businesses, cut 
Medicare for seniors, and raise health care premiums. The bill raises 
taxes by $730 billion and costs nearly $1.3 trillion. We literally 
cannot afford this plan.
  There is a better way, however. The Republican health care plan is a 
responsible, targeted approach to reform. It doesn't raise taxes during 
a recession or cut Medicare. It will lower premiums, making coverage 
more affordable for families and employers while reducing the deficit 
by $68 billion. Commonsense ideas like medical liability reform, 
strengthening association health plans, and allowing people to purchase 
health insurance across State lines will make health care more 
affordable without breaking the bank.
  The choice is simple. Mr. Speaker, I urge my colleagues to oppose 
Speaker Pelosi's health care bill and support the Republican 
alternative.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Maryland (Ms. Edwards).
  Ms. EDWARDS of Maryland. I thank the gentleman for yielding.
  Mr. Speaker, I rise today in support of this historic legislation. It 
is the most historic in a generation. H.R. 3962 will indeed change the 
face of health care in this country. This bill really is not about 
partisanship and it's not about politics, but it is about the American 
people; and it's time for us to deliver on our promise to them.
  As I've listened to my colleagues today talk about why this bill is 
good for their districts for the uninsured, for men, for women, for our 
seniors, I'm reminded that I was indeed once one of those uninsured. As 
a young mother, I became so sick that I collapsed in a grocery store, 
and I was taken to an emergency room. Without health care insurance, I 
was treated. I was one of those uncompensated. Now it's time for me to 
pay the American people back with a vote for comprehensive health care 
reform.
  This bill will take the burden off providers and Americans for paying 
the cost of uncompensated care and safeguards for the health of all 
Americans. It lowers costs and ends discriminatory insurance industry 
practices such as denying women coverage for pregnancies or a history 
of domestic violence.
  Mr. Speaker, it's time for us to have the courage to rise above our 
pecuniary interests.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I'm very pleased to 
yield 1 minute to my friend and colleague, the gentleman from Ohio (Mr. 
Jordan).
  Mr. JORDAN of Ohio. I thank the gentleman for yielding.
  Mr. Speaker, how bad does it have to get? How bad does it have to get 
before we stop the out-of-control spending? A $1.4 trillion deficit, a 
$12 trillion national debt, a trillion dollars in bailouts and 
stimulus, and now here we come again with $1.3 trillion takeover of our 
health care system.
  One of the things that makes this country so special, one of the 
things that makes this country the greatest Nation in history is this 
simple concept, that parents make sacrifices for their children so that 
when they grow up, they can have life a little better than we did, and 
then they in turn do it for the next generation, and each generation in 
this country has done it for the one that succeeds them.
  And now, unfortunately, what we are doing is borrowing and spending 
and living for the moment and passing the bill on to our kids. It's 
wrong and it should stop here.
  Vote this bill down. Support the Republican alternative.
  Mr. KLINE of Minnesota. Mr. Speaker, can I inquire as to exactly the 
time remaining for each side.
  The SPEAKER pro tempore. The gentleman from Minnesota has 5 minutes 
remaining, and the gentleman from California has 5 minutes remaining.
  Mr. KLINE of Minnesota. Mr. Speaker, I am pleased at this time to 
yield 1 minute to the gentleman from Kansas (Mr. Moran).
  Mr. MORAN of Kansas. Mr. Speaker, the Pelosi health care bill creates 
111 new bureaucracies and it only cuts one program: Medicare.
  I chair the Rural Health Care Coalition. I care about health care 
especially as it affects rural States, rural Americans like Kansans. 
And I have concluded that this bill will not make health care more 
affordable or more accessible for rural America. The standard by which 
I judge this is not a Republican plan or a Democrat plan, but what is 
good and right for America.
  I've concluded that coupled with all the other bad ideas of this 
Congress--stimulus packages, bailouts, Cash for Clunkers, cap-and-
trade--we will be leaving our children with more debt, less freedom, 
diminished personal responsibility, and fewer economic opportunities. 
Worse, we will have failed to honor the dreams for a better life for 
another generation of Americans. This I will not, cannot support.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentlewoman from Texas (Ms. Eddie Bernice Johnson).

                              {time}  1930

  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in strong 
support of this bill, H.R. 3962, the Affordable Health Care for America 
Act. It is a long time we should have been here. We have been trying 
this for so very long.

[[Page 27483]]

  You know, if this bill said anything as bad as what I have heard from 
the Republicans, I wouldn't support it. But it does not do that. I 
don't know what bill they are reading.
  I want to share, though, that I know this will bring relief to my 
constituents. In my district, there are 35.6 percent of the residents 
uninsured, and the adjoining district, District 32 of Texas, has about 
the same number, but we are on different sides for bringing that 
relief.
  The American people have heard so many untruths, they must be 
confused. Having access, though, to better coverage will show them what 
the truth is. This bill is a win for all Americans. I stand in strong 
support of this legislation and urge my colleagues to vote in favor of 
this bill.
  Mr. KLINE of Minnesota. Mr. Speaker, I am pleased to yield 1 minute 
to another physician, the gentleman from Louisiana (Dr. Fleming).
  Mr. FLEMING. It has been mentioned many times during this debate that 
the AMA and the AARP have endorsed this. However, the polls show that 
the majority of physicians oppose this. And the polls say that the 
majority of seniors oppose this bill, the Pelosi health care takeover.
  Who is going to be hurt in this? Individuals will be required to pay 
2.5 percent taxes or go to jail; 5.5 million of them will be 
unemployed. Businesses will be required to pay 8 percent payroll tax, 
and then an additional excise tax of 5.4 percent, bringing the marginal 
rate to 45 percent. States will have an increase in unfunded Medicaid 
mandate. Who is going to pay for that?
  Mr. Speaker, seniors will see $500 billion, half a trillion dollars, 
removed from their access to care.
  I urge my colleagues to vote ``no'' on Pelosi health care.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentlewoman from California (Mrs. Davis).
  Mrs. DAVIS of California. Mr. Speaker, as chair of the Consumer 
Protection Committee in the California State Assembly, I worked hard to 
maintain and improve the protections and the rights that Americans 
deserve.
  In the health care industry, which is really the most important of 
all sectors that deal with people's basic needs, millions of consumers 
are being taken advantage of on a daily basis and have few rights.
  This bill changes that. It changes that and it puts us on the track 
of giving Americans and their families the peace of mind that they will 
never lose their health coverage.
  I look forward to voting on this historic bill which puts consumers 
and puts Americans first.
  Mr. KLINE of Minnesota. Mr. Speaker, I am very pleased to yield 1 
minute to the distinguished gentleman from Oklahoma (Mr. Cole).
  Mr. COLE. Mr. Speaker, I respect, like all Members do, everybody in 
this House, from the Speaker and the minority leader right down to the 
most junior Member. But the reality is, this isn't our House; this is 
the people's House. As I have listened to my friends on the other side, 
I have wondered, frankly, did you listen to what the people had to say 
in August in meeting after meeting after meeting? Have you taken the 
time to look at what they say in poll after poll after poll?
  This is not an issue that has come on us suddenly. It is not a 
crisis. The American people have had a chance to study the issue, read 
the bill, and listen to the debate, and quite frankly, register an 
opinion. If we listen to them today, Mr. Speaker, we will follow their 
loud and insistent voice and vote ``no.''
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentleman from California (Mr. Farr).
  Mr. FARR. Mr. Speaker, I am ashamed on this great day of hope to hear 
so much fear, fear outside and fear inside. And I don't think they know 
fear. I know the fear of a woman carrying a baby dying because she has 
no access to health care. I saw that over and over again as a Peace 
Corps volunteer in Latin America.
  Without health care, you can't start the day. You can't get up. You 
can't cope. You can't go to work. You need health care.
  Combat that fear. Combat those fearmongers out there. Stand up for 
hope. Say ``yes'' to health care for all Americans. Vote ``yes'' for 
compassion. Vote ``yes'' for care. Vote ``yes'' for healing and health. 
Vote ``yes'' for my grandchildren.
  My first exposure to real poverty was as a Peace Corps volunteer in 
Medellin, Colombia. People there lived hard-scrabble existences, barely 
eking out subsistence-level lives.
  My role as a Peace Corps volunteer was to help the community organize 
and petition its government for basic resources to improve the lives of 
the people. What I learned in that barrio is that unless people have 
shelter, unless they have food, and unless they have health care,--
yes--health care, there can be no stability in the community and no 
confidence in the future. People need to have their health in order to 
cope and to be productive.
  The lesson I learned in Colombia 45 years ago is still true today in 
the U.S.A., people in health care limbo can't focus on the future. They 
are too busy worrying about today.
  History teaches us that America was built on neighbor helping 
neighbor. Colonists clung together in the New World and protected each 
other. Settlers out West never turned away a traveler. I am ashamed and 
amazed at the tone of debate today that would deny our fellow Americans 
access to health care coverage. That is not the American way. When did 
we become so selfish? At a time of historical hope why are we hearing 
so much about fear?
  There is nothing to fear--tomorrow or a year from tomorrow you will 
still have you insurance policy, hospitals and doctors will be doing 
their jobs of caring and healing and for the first time the hope for 
health care for all will come true.
  Tonight we are asked to make history--leadership is about getting 
results. To make just law we have to vote yes. I am proud to say 
``yes'' to health care for all in America. ``Yes'' to compassion and 
care. ``Yes'' to healing and health. ``Yes'' to my grandchildren's 
future.
  Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to 
the gentleman from South Carolina (Mr. Inglis).
  Mr. INGLIS. Mr. Speaker, I identify with the sentiments of the 
gentleman who just spoke. The only problem is if you look at Martin 
Feldstein's article yesterday in The Washington Post, what you see is 
that we are going to have another problem with the cost of this, that 
as folks have a problem with the cost shift continuing, we are actually 
going to make insurance more expensive, and actually people are going 
to lose coverage because they are going to decide to go bare until they 
get sick, then access the guaranteed issue, then cause premiums to 
rise, which will actually cause more people to be uninsured.
  So the mandate here doesn't work because the penalties aren't high 
enough in the mandate to keep people from deciding to go bare until 
they are diagnosed with a problem.
  The result will be that we actually end up with more people uninsured 
and higher premiums. The bill needs to be rethought. That is the kind 
of thing that we could develop in a collaborative process. That's not 
the process here. That's why we have this problem.
  Mr. GEORGE MILLER of California. I yield to the gentleman from 
Massachusetts (Mr. Olver) for the purpose of making a unanimous consent 
request.
  Mr. OLVER. Mr. Speaker, I rise in favor of H.R. 3962.
  Mr. Speaker, we often hear that America has the best health care 
system in the world.
  But, our health care system largely takes care of those who are lucky 
enough to be able to afford it.
  In the past decade, the premiums charged by private health insurance 
companies have risen more than 75 percent while workers' wages have 
risen less than 25 percent.
  To add insult to injury, the profits of the 10 largest health 
insurers have risen by 400 percent, and the salaries of their CEO's 
have tripled.
  America now has 50 percent higher health care costs than the highest 
of the next 20 most industrialized nations.
  Yet, Americans suffer the highest infant mortality rate among the G-7 
countries. Our infant mortality rate is 50 percent above the average 
for the other 6 countries.
  American life expectancies are more than 2 years lower than the 
average for the other 6 countries.

[[Page 27484]]

  Clearly, we have the most expensive health care system in the world, 
but, equally clearly we don't have the best.
  We can and must do better. We must reverse these trends.
  This is our chance to fix a broken system.
  I am proud to vote in favor of H.R. 3962, the Affordable Care for 
America Act.
  For the 50 million Americans who still do not have health insurance, 
this historic legislation guarantees you will have good insurance--
insurance that you can afford--which provides a sliding scale of 
credits available to families that earn up to 400 percent of the 
federal poverty standard, or $88,200 for a family of 4.
  For those of us that are lucky enough to have health insurance, this 
legislation LL provides added stability by immediately banning lifetime 
caps and by 2013 eliminating pre-existing condition exclusions and 
annual caps on insurance coverage. You cannot be denied coverage.
  For those who are concerned about losing or having to switch jobs--
especially important in our current economy--this bill brings you added 
stability. You will always have access to affordable, quality health 
insurance.
  For senior citizens on Medicare, H.R. 3962 protects your benefits. We 
know that seniors live on largely fixed incomes. As such, this bill 
puts money back into your pockets by reducing the donut hole 
immediately by $500 and immediately cuts the cost of brand name drugs 
in half for those who still find themselves in the hole. Furthermore, 
the donut hole is completely closed by 2019. The bill provides free 
Prevention and Wellness care and saves seniors money by reducing 
copayments and cost-sharing.
  Finally, H.R. 3962 makes major investments in primary care so that we 
will have the critical infrastructure in place to efficiently combat 
the steady rise of deaths from preventable illness in this country. 
Between 1997 and 2002, when researchers compared preventable deaths--
from diabetes, cancer, and heart disease amongst others--in 19 
industrialized countries, the United States placed last. During those 
years alone, at least 75,000 men, women and children died because they 
lacked access to quality preventive care. Furthermore, H.R. 3962 makes 
new critical investments in training primary care providers, helping 
them with overwhelming student loan debt and paying them well for their 
service.
  This is a historic time in our country's history. This bill makes the 
critical investments that are needed to turn our health care system 
around and provide the health care that our citizens deserve.
  I am proud to cast my vote in favor of this monumental legislation.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentleman from Tennessee (Mr. Cohen).
  Mr. COHEN. Mr. Speaker, this debate in the House is part of a 97-
year-old debate in America. It started with a Republican, Teddy 
Roosevelt, and continued with Democrats Harry Truman and Lyndon 
Johnson, then a Republican, Richard Nixon, who, while short on 
veracity, was great on policy and government. It continued through Bill 
Clinton, and now we are in a day when we have a chance to accomplish 
something worthwhile, something Daniel Webster tells us we should do 
while we are here in our generation and our time, to do something 
worthy of being remembered.
  Theodore Roosevelt said, In this world the only thing supremely worth 
having is the opportunity, coupled with the capacity, to do well and 
worthily a piece of work, the doing of which is of vital consequence to 
the welfare of mankind.
  I plan to take my voting card, along with hopefully at least 218 
others, and do something that Teddy Roosevelt would see as proper, and 
provide health care for Americans.
  The SPEAKER pro tempore. The gentleman from Minnesota and the 
gentleman from California each have 1 minute remaining.
  Mr. KLINE of Minnesota. Mr. Speaker, I yield myself the balance of my 
time.
  Mr. Speaker, let me just say that what we have before us here is a 
true loss for American families seeking quality health care and 
American workers seeking quality jobs. It is remarkable that our 
colleagues believe 2,000-plus pages of more red tape, more power in the 
hands of the super bureaucrat, more taxes will do anything other than 
make health care more costly and more complicated and kill more jobs in 
this country.
  Why, when we have a 10.2 percent unemployment rate, the highest in a 
quarter century, would we ever want to pass legislation that will 
destroy millions of jobs? It defies logic. Why would we want to strip 
Medicare from the seniors who depend upon it? Why would we want to pile 
debt on our children and grandchildren? Why would we want to raise 
health care costs? Why would we want to raise taxes? I have yet to hear 
an answer to these questions.
  This bill is not health care reform. The American people deserve 
better than this. We can do better than this. Let's make the right 
decision. Stop this Big Government takeover of health care and return 
to the table for real reform.
  I yield back the balance of my time.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield to the 
gentleman from Pennsylvania for the purpose of a unanimous consent 
request.
  Mr. FATTAH. Mr. Speaker, I support this bill, and I thank the 
chairman for yielding me the time.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the 
gentleman from Minnesota (Mr. Oberstar).
  Mr. OBERSTAR. Mr. Speaker, I have advocated a national health care 
system as long as I have served in Congress. Today we take a decisive 
step toward that goal.
  This is not a perfect bill but a good bill. The three committees have 
worked hard to address the needs of the people of my district, and my 
own concerns, regional disparities in Medicare reimbursement that 
penalize Minnesota health care providers, and ensuring taxpayer dollars 
are not used to fund abortion services.
  Last summer I met with the Skare family in Cloquet. Their son, born 
with a congenital liver disease, required a liver transplant as a 
child. Today he is 20 years old. The family is buried under mountains 
of medical bills, despite having health insurance. They constantly have 
to fight the insurance providers to make them live up to their 
commitments. This bill will ensure that families like the Skares will 
not be held hostage to insurance companies. It will protect all 
Americans from being denied coverage due to preexisting conditions.
  Today, we keep faith with the American people. Today we ensure that 
quality, affordable health care is available to everyone. Support this 
bill.
  Mr. Speaker, throughout my service in the House of Representatives, I 
have been a strong proponent for a national health care system to 
ensure that all Americans have access to affordable health care. Our 
current health care system is paradoxical. While our nation can take 
credit for having the best trained health care professionals and the 
most advanced medical devices, far too many Americans do not have 
access to essential health care. Our current health care system has 
failed this fundamental fairness principle, and as a result, health 
care has been rationed in this country with more than 46 million 
Americans without health insurance.
  Long before the November 2008 elections and the beginning of this 
Congress, there has been near universal agreement that health care 
reform is necessary, and that the cost of inaction is unacceptable. 
Today represents an important opportunity to make health care more 
affordable and more accessible to more Americans.
  Comprehensive health care reform involves more than just extending 
access to the uninsured. The explosion of health care costs has created 
tremendous challenges for the private sector that has hindered our 
ability to compete in the global marketplace. Additionally, it is 
imperative to constrain health care spending that consumes an 
unsustainable percentage of our federal budget. Health care reform is 
vital to the nation's economic recovery and fiscal responsibility.
  I commend the leadership of the three committee chairman who have 
worked tirelessly to craft legislation to repair what is not working 
well and preserve what is working in our health care system. Thank you, 
Charlie Rangel, Henry Waxman, and George Miller for your dedicated 
efforts to seize this historic opportunity and produce a sensible 
health care bill that builds upon and improves the employer-provided 
and private health insurance market.
  I am very pleased that the House health care bill (H.R. 3962) 
includes many essential reforms that will improve health care. The 
health insurance provisions to ensure that

[[Page 27485]]

Americans will not be denied coverage due to a pre-existing condition, 
the requirement for guaranteed issue and renewal, and the limit on out-
of-pocket spending are much needed reforms that will make health 
insurance more available and affordable. For seniors, I strongly 
support the funding to close the donut hole in the Medicare Part D 
prescription drug program.
  I am also delighted that H.R. 3962 contains provisions to address the 
historic disparities in Medicare reimbursement that have long penalized 
Minnesota and other high-quality, low-cost states. I greatly appreciate 
the dedicated work of my colleagues in the Quality Care Coalition 
(Betty McCollum, Ron Kind, Bruce Braley, Jay Inslee) to include 
language that will promote Medicare geographic equity. I believe that 
the requirement for the Secretary of Health and Human Services to 
implement the recommendations of an Institute of Medicine study will 
lead to Medicare payment reform that will reward value, not volume. 
This payment reform is one of my biggest priorities because in 2007, 
Medicare paid Minnesota hospitals $1 billion below the actual cost of 
care.
  While I am very pleased that the House will have the opportunity to 
vote on amendment to ensure that taxpayer dollars are not spent for 
abortion, I am disappointed that several important amendments were not 
made in order. It was expected that the House would consider an 
amendment that would create a single-payer system for health care. 
While I continue to have great concerns about a single-payer system 
based on Medicare rates, I would have supported the single-payer 
amendment. I am disappointed that the Kucinich amendment which was 
supported in the committee mark-up to enable states to develop their 
own innovative state programs was stricken from the bill, and we do not 
have the opportunity to restore this language.
  I am also disappointed, however, that the House health care bill does 
not contain a number of important policy reforms recommended by the 
National Rural Health Association (NRHA). The NRHA made more than ten 
specific recommendations regarding longstanding payment inequities that 
were unfortunately not addressed in this bill. I am especially troubled 
that several rural health improvements that were accepted in committee 
mark-up were not included in the updated House bill. It is essential 
that provisions to ensure rural representation on MedPac, and 
improvements in the 340B Drug Pricing program and the super rural 
ambulance reimbursement are restored in conference. I am also hopeful 
that the final conference report will include legislation that 
Minnesota's Senators and I have authored to provide Critical Access 
Hospital designation for a hospital in Cass County, Minnesota which I 
hope the Senate will include in their bill.
  I strongly believe that Minnesota's leadership in health care reform 
should serve as a model for national reform. Minnesota is unique in 
requiring all health maintenance organizations (HMOs) to be nonprofit 
as a condition of licensure. Minnesota extended health care coverage to 
lower-income children long before the enactment of the federal SCHIP 
program, and Minnesota has done a better job in expanding access to 
care through its MinnesotaCare program than the rest of the nation. 
Minnesota has led the nation on integrated health systems to coordinate 
care, and a new partnership between Fairview Health and the Medica 
health insurance company that provides payment incentives to invest in 
health care rather than paying for ``sick care'' demonstrates 
Minnesota's continued leadership that is far ahead of national 
policymakers.
  Even with the expected improvement in Medicare reimbursement that 
will benefit Minnesota, I am concerned in many respects that Minnesota 
is picking up the tab to pay for national health reform. While I 
understand and support the need to reduce the excessive payments in the 
Medicare Advantage program, it is far easier for high-cost states to 
absorb a 14 percent cut than for Minnesota which receives significantly 
less in Medicare Advantage payments. I am also concerned with the 
addition of a tax on medical devices that will negatively impact 
Minnesota's important medical device industry, as well as changes in 
the second generation biofuel producer credit that will preclude 
``black liquor'' from eligibility for this biofuel credit that will 
impact the wood product industry in Minnesota. I will strongly 
encourage modifications in the financing in the final version to ensure 
fairness for Minnesota.
  During the thorough discussion and debate regarding health care this 
year, I have greatly appreciated the opportunity to visit with 
constituents in Minnesota and in Washington. From seniors and health 
care providers to organized labor, the small business community and the 
faith community, I have gained valuable insights and recommendations to 
improve this legislation.
  While I recognize and understand there are still many issues that 
need to be addressed, I am prepared to support this legislation today 
to move this necessary process forward.
  Mrs. LOWEY. Mr. Speaker, I rise in support of the Affordable 
Healthcare for America Act.
  Over the last eight months, I have communicated with tens of 
thousands of my constituents in Westchester and Rockland Counties in 
meetings, conference calls, round-tables, telephone town halls, and 
neighborhood office hours.
  Among people from of all walks of life--small business owners, 
doctors, patient advocates, and seniors--one constant is the passion 
which most agree on the need for health care reform despite different 
opinions on how best to achieve reform.
  Since 2000, personal premiums have more than doubled.
  Since 1987, the cost of the average family health insurance policy 
has risen from 7 percent of the median family income to 17 percent.
  In 2007, 60 percent of all U.S. bankruptcies were due to medical 
costs.
  The U.S. is on track to spend nearly $33 trillion on health care over 
the next decade.
  The financial security of our families, businesses, and our overall 
economy depends on meaningful health care reform.
  That's why I will support this bill today to:
  Provide health coverage to approximately 36 million Americans, 
including 39,000 residents in my congressional district.
  Help small businesses who are struggling to provide coverage to their 
employees while exempting 86 percent of the smallest businesses from 
the requirement to do so.
  Ensure that reform is fully paid for while exempting 99.7 percent of 
all American households from paying a health care surcharge.
  Guarantee additional protections to those who have insurance, 
including ending discrimination for pre-existing conditions; limiting 
annual out-of-pocket costs; and preventing health insurance companies 
from dropping your coverage if you become sick.
  Improve and strengthen Medicare.
  Now, this bill is not perfect. I am deeply disappointed that the 
House approved language which puts new restrictions on women's access 
to abortion coverage in the private health insurance market even when 
they would pay premiums with their own money.
  If we want to reduce abortions we should give millions of women 
health coverage so they can get regular reproductive care, 
contraceptives to prevent unintended pregnancies, and prenatal care to 
ensure healthy pregnancies.
  Despite this damaging provision, we must move forward in improving 
health coverage for those who have it, providing coverage for those who 
don't, and controlling costs throughout the system.
  I urge my colleagues to support this legislation.
  Mr. LOEBSACK Mr. Speaker, this August and September I held 16 town 
halls across the 2nd District of Iowa. I heard from countless Iowans 
about the need to change the current health care system. Though some 
disagreed with provisions in the original House proposal, almost 
everyone agreed that the fact that a family in Iowa pays an extra 
$1,100 per year in premiums to support a broken system was 
unacceptable. So I am proud to be a part of a Congress that decided the 
status quo is no longer acceptable. Iowa families want stable health 
care coverage that can't be taken away, they want greater choices, and 
they want to know that if they get sick they won't be forced into 
bankruptcy. The Affordable Health Care for America Act answers these 
calls to action and I'm proud to support a bill that is good for 
Iowans.
  This legislation keeps what works in the current system and fixes 
what doesn't. If you like your current health insurance and you like 
your doctors you can keep them. If you don't have health insurance, you 
will be able to acquire it. In fact, some of the greatest changes from 
the original House proposal to the bill we are considering today are 
the immediate reforms. We aren't saying wait for coverage, we are 
saying the status quo is not fair and we will no longer tolerate it 
starting right now.
  There will be help for hardworking families now. The revised bill 
immediately creates an insurance program with financial assistance for 
those who have been uninsured or denied coverage because of pre-
existing conditions, and fills the gap until the Health Insurance 
Exchange is up and running. The bill immediately prohibits health 
insurance companies from rescinding coverage. If you find out you are 
sick one day, you don't have to worry that your health insurance will 
be taken away the next.
  The revised legislation also immediately prohibits health insurers 
from utilizing lifetime limits on benefits, and extends COBRA 
eligibility

[[Page 27486]]

to permit individuals to remain in their COBRA policy until the Health 
Insurance Exchange is up and running. America's Affordable Health Care 
for America Act also makes immediate changes to improve the health and 
well being of our seniors. The legislation begins closing the Medicare 
Part D Donut Hole in January. There will also be an immediate 50 
percent discount for brand name drugs in the donut hole.
  In addition to the immediate benefits, this legislation takes a 
comprehensive approach to long-term reform. I am a native Iowan, and 
since I came to Congress I have been committed to fixing the broken 
Medicare payment system. The geographic disparities in the system have 
caused problems not only for providers in my District, but also for the 
patients.
  I have always been proud of how hospitals in my District have 
achieved so much under the constraints of the current Medicare payment 
system. With some of the lowest reimbursement rates in the country, 
they provide some of the highest quality care. However, the current 
system is broken and now I'm proud to say that the Affordable Health 
Care for America Act reforms Medicare payments so that they are based 
on the quality of services rather than the quantity of services. This 
fix benefits not just Iowa, but all of America.
  I also want to mention another provision with direct benefit to Iowa 
in this legislation. According to a 2008 Institute of Medicine report, 
Retooling for an Aging America: Building the Health Care Workforce, in 
the near future, the nation will be aging dramatically, leading to an 
increase of older adults from 12 percent of the U.S. population in 2005 
to almost 20 percent by 2030.
  As the population ages, their health care needs will increase, and 
they will need additional supports. In the same report, it's stated 
that meeting the demand that is expected in coming years will require 
expansion of the roles of many members of the health care workforce, 
including technicians, direct-care workers and informal caregivers, all 
of whom already play significant roles in the care of older adults.
  I was very pleased to have language included in this bill that takes 
much needed steps towards meeting these workforce demands, as well as 
other projected long-term health needs. The provision encourages the 
identification, promotion, and implementation of investments in the 
long-term care workforce and assists States in developing comprehensive 
state workforce development plans.
  It also creates a Workforce Advisory Panel which will identify core 
competencies for long-term care workers and recommends training 
curricula and resources for these workers. The bill also creates a 
demonstration project to evaluate the Panel's recommendations. In 
addition, this legislation improves assistance to family and informal 
caregivers, and improves the dissemination of information to seniors 
regarding their long-term care health insurance options.
  In a recent guest column in the Des Moines Register, John Hale from 
the Iowa Caregivers Association, highlighted the efforts that Iowa has 
already undertaken on long-term care workforce shortages and spoke 
about the national need to address these issues. Mr. Hale stated that, 
``Access to coverage does not equal access to care.'' I could not agree 
more.
  Federal support is essential in helping all states continue to look 
at both workforce shortages and the core competencies that should be 
required of those in the field. I have said many times in the past 
weeks and months that quality health care is the key to patient 
outcomes. I am glad this legislation takes much needed steps to support 
our long-term care workforce.
  There are many more important provisions in this legislation and in 
the coming days, weeks, and months I look forward to discussing this 
bill, and what it does for Iowans, with my constituents. I look forward 
to voting for the Affordable Health Care for America Act, and 
abolishing the status quo.
  Mr. WESTMORELAND. Mr. Speaker, on this bill the Congress is scheduled 
to vote on today will cost more than $1.3 trillion over the life of the 
bill.
  It'll expand entitlement spending, it'll raise taxes on small 
business payrolls, it'll cost jobs by mandating coverage that some 
businesses can't afford, it'll put government in between the doctor and 
the patient, and it'll cut Medicare funding. By expanding Medicaid 
eligibility, the legislation puts new burdens on states that already 
are struggling to pay their bills. The states share the cost of the 
Medicaid program, and this could cost my home state $2 billion to $4 
billion over the next 10 years. That's a huge share of Georgia's state 
budget, and it's a cost we simply can't bear.
  But, luckily, there is a better way. Republicans are providing that 
alternative, although the Democrats continue to insist we're not 
offering ideas. We are. They just don't want Americans to know it.
  Ms. SPEIER. Mr. Speaker, today, I look forward to keeping my promise 
to the voters and taxpayers who sent me to Congress by casting a vote 
for a historic health care reform bill that has been sixty years in the 
making.
  Still, with any effort as far-reaching as reforming health care, 
Americans are right to ask: ``What's in it for me?''
  Well, I'll tell you.
  If you are a woman, this bill has plenty for you. You know, far too 
well, that our fight for equality is not limited to the board room. We 
must fight for our rights in every line of fine print in every 
insurance contract. The fact is that women's health care premiums cost, 
on average, more than 145 percent of the price of a similar man's 
policy. Even then, women are more likely to be denied coverage for a 
pre-existing condition, including for things as common as getting 
pregnant (or the inability to get pregnant) having a c-section, even 
being a survivor of domestic violence. With the passage of this health 
care reform bill, these practices will be tossed on the ash-heap of 
history atop corsets, chastity belts and other limitation on women's 
rights and equality. In fact, with this bill, America's mothers, wives 
and sisters will finally enjoy the same health care coverage that their 
fathers, sons and brothers have.
  If you are an American of retirement age, this health care reform 
legislation contains provisions that ensure high quality, effective 
health care throughout your retirement years. We have heard your 
frustrated calls to end the ill-conceived Medicare Part D donut hole 
and responded by immediately reducing the hole by $500 and, by 2019, 
getting rid of it once and for all. The bill also cuts in half the cost 
of name-brand drugs. No older American should ever have to decide 
between purchasing food or the life-saving medicine prescribed by their 
doctor.
  When Congress voted for Medicare nearly 45 years ago, this House 
promised seniors quality, affordable health care in their retirement. 
They did this despite a future president, Ronald Reagan, decrying 
Medicare as socialism--sound familiar?
  Well, by cutting waste, fraud and abuse, eliminating the out-of-
pocket payments for preventative care and banning overpayments, this 
Congress is making good on that promise and extending the Medicare 
trust for future generations.
  If you are one of the 14,000 Americans who lose their health 
insurance coverage every day, this bill offers comfort and hope when 
you are most in need. Just last night during a telephone town hall a 
constituent told me how, at 55 years old, she lost her job and her 
health coverage. She wonders if, even after the economy recovers, she 
will be able to get a job--at her age--that provides health care. 
Today, when workers like her lose their job and their coverage, they 
are forced into the snake pit that is the individual insurance market 
where insurance company practices like denying coverage because of a 
preexisting condition are common. Fortunately this practice, along with 
dropping customers once they fall ill, has been outlawed in this bill. 
Also, while the health care exchange--which will provide access to 
affordable, quality health care--is being set up, a high-risk insurance 
pool will be available so that you have coverage in the meantime.
  For the majority of Americans who have health insurance through their 
employer, you get the best news of all. I don't have to tell you that, 
since 2000, employer-sponsored health insurance premiums have more than 
doubled. Your employer's real health care costs have risen at a rate 
that is three times faster than wage increases and business profits. 
This is, quite simply, unsustainable. If we took a page from the 
opposition party and did nothing, the cost of employer-sponsored family 
health insurance plans would reach $24,000 in less than ten years. This 
same price spike would result in families spending 45% of their income 
on health insurance. Also, the insurance exchange will allow you or 
your employer to purchase coverage from health plans that meet 
guaranteed benefit levels, cap annual out-of-pocket spending and end 
annual and lifetime benefit limits. There will also be a public option 
that is completely self-supported by premiums.
  This is not a decision that has been made in haste. No issue has been 
studied, scrutinized and debated more than health care reform. And, 
like every time in our nation's history when sweeping changes are 
proposed-- whether it be Social Security, Medicare, civil rights, 
women's suffrage or the creation of the Veterans Administration--
emotions have run high in this debate and there has been no shortage of 
opinions on every side.
  The bill we are set to vote on is a compromise between many different 
points of

[[Page 27487]]

view. It is the result of the most exhaustive and transparent review 
process of any bill in our nation's history, with hundreds of hours of 
bipartisan committee meetings being devoted to it and the final text 
being posted on-line more than three days prior to a vote being taken. 
Compare that to the Republicans Medicare Part D bill in 2003 which was 
forced to a vote just hours after the bill was printed.
  It will be a proud day for this Congresswoman--and for America--when 
Congress finally sets our nation on a path toward greater access, 
greater equality and greater accountability and competition in our 
health care system.
  This is what my constituents sent me here to do. And I am happy to 
oblige.
  Mr. LATHAM. Mr. Speaker, everyone agrees that health care costs too 
much in this country, but we can fix the problem without a trillion-
dollar government takeover of health care. The bill before us now takes 
us in the wrong direction. It slashes Medicare and pins small 
businesses with job-killing taxes and mandates, at a time when our 
economy is struggling and unemployment is over 10 percent.
   More federal controls on the content of insurance policies have 
nothing to do with covering the uninsured and will increase costs for 
most families rather than decrease them. If you have coverage through 
an employer, your premiums will go up. If you have an individual 
policy, you will have to switch to a federal exchange plan in 2013 or 
face a fine or, possibly, jail time for not having federally qualifying 
coverage that you may not be able to afford. Younger people in 
particular could see their premiums increase by more than 70 percent.
  Instead of taking the approach we are taking today, we should 
implement common-sense reforms that focus on covering the uninsured and 
lowering health care costs. We must ensure those with pre-existing 
conditions get quality coverage. We can lower costs by requiring 
insurance companies to compete nationwide, and we can clamp down on 
frivolous malpractice lawsuits. Most of the uninsured work for small 
businesses that cannot afford health insurance for their employees, and 
we should allow small businesses to pool together for lower premiums. 
Such reforms have bipartisan support and could be enacted immediately 
to provide relief for millions of Americans struggling with health 
insurance costs.
   On another note, this bill contains no guarantee that Iowa's 
Medicare reimbursement rates--which are among the lowest in the 
country--will see any sort of increase. At the same time, this bill 
specifically increases Medicare payments in 14 counties in California, 
the home state of Rep. Henry Waxman, one of this bill's main authors. 
This may be viewed as reform by some, but it is certainly uneven reform 
for those counties in our districts that do not benefit from such 
increases.
   Throughout the summer and early fall, more than 12,400 residents of 
Iowa's 4th Congressional District responded to my health care survey. A 
majority were unsatisfied with the state of health care in America, and 
rightly so. More than 70 percent of respondents ranked cost as the most 
pressing concern regarding health care in the United States, followed 
by access at 14.6 percent and quality at 8.4 percent. However, 86 
percent described the quality of their personal health care as either 
``excellent'' or ``good'' and they do not want to be forced to give up 
coverage they are satisfied with. Some 65 percent said the government 
should play ``no role'' or a ``minor role'' in determining health 
insurance options for Americans. My constituents support common sense 
solutions. Approximately 64 percent support doing away with exclusions 
for preexisting conditions, 75 percent thought people should be allowed 
to purchase health insurance across state lines, and 69 percent support 
small business health plans.
   To sum it all up, this bill is clearly not what is advertised by its 
supporters and it is not what my constituents want. We need to go back 
to the drawing board and produce a bill with common-sense solutions 
that the vast majority of Americans support.
  Mr. CASSIDY. Mr. Speaker, I have spent 20 years caring for the 
uninsured in Louisiana's public hospital system.
  Skyrocketing costs put quality care out of reach for too many 
Americans, and I appreciate that everyone agrees the status quo is 
unacceptable.
  All agree on the goals of reform: lower costs and expand access to 
quality care.
  Unfortunately, this bill does not achieve our goals.
  The Congressional Budget Office says it raises costs.
  Without lowering costs, access or quality will suffer.
  Its effects will be radical, but this is not a radical bill.
  It turns insurance bureaucrats into federal bureaucrats.
  There's no innovation, just nationalization.
  Real reform would revolutionize health care.
  Real reform would give patients, not bureaucrats, the power.
  Unless patients are empowered with control over health care dollars 
and decisions, costs will not be lowered and access will not be 
expanded without sacrificing quality.
  The road to real health reform begins with stopping this bill today.
  I urge my colleagues to join me in this effort.
  Mr. PRICE of North Carolina. Mr. Speaker, as the House of 
Representatives approaches this historic vote, my mind travels back to 
the formative years when I first became engaged in politics, and also 
to hundreds of meetings I have had with constituents since the citizens 
of North Carolina's Fourth district first sent me to Congress.
  I came of age as the civil rights movement of the late '50s and early 
'60s swept across the country. It shaped and transformed my social, 
religious, and political views. I remember the culminating moment in 
1964 when, as a Senate staff member, I crowded into the gallery and 
witnessed the dramatic passage of the Civil Rights Act of 1964.
  That momentous bill marked an expansion of democracy and of access to 
opportunity for millions of Americans. Today's vote is also momentous, 
and it also marks an expansion of democracy's promise. Today we resolve 
that never again will American citizens be denied access to health 
insurance, and that one of life's most basic needs--health care--will 
be available to all of our people.
  As I think back on my years of congressional service, I remember 
meetings with parents terrified at the prospect that their children 
with serious illnesses would not be able to obtain coverage when they 
reach adulthood. I remember maddening stories of families coping with 
illness while simultaneously fighting with insurance companies. I 
remember young adults unable to buy affordable insurance, often because 
of allergies or other minor conditions. I remember retirees not yet 
eligible for Medicare being quoted rates of thousands per month because 
of their health history.
  Mr. Speaker, we have all heard these stories. They are unworthy of 
our country. And today we have the opportunity to bring such hardship 
and heartache to an end. The American people deserve a health care 
system that works for them--one that provides access to stable 
coverage, quality care, and affordable premiums and copayments. The 
legislation before us today will correct the failures of the American 
health care system without compromising its many strengths or adding to 
the budget deficit.
  If you have coverage at work, you'll be able to keep it--but the loss 
of a job will no longer mean the loss of affordable coverage. And your 
insurance company will no longer be able to impose lifetime benefit 
limits; discriminate on the basis of age, gender, or pre-existing 
conditions; or cancel your policy if you get sick.
  If you have coverage through Medicare, you'll have more benefits and 
lower out-of-pocket costs, including no more copayments for preventive 
and many diagnostic services, and a 50 percent discount on your brand-
name prescriptions, and a progressive closing of the gap in coverage 
known as the ``doughnut hole.''
  If you don't have coverage at all, you'll be able to buy it on the 
National Health Exchange at the same affordable group rates that big 
companies have always been able to negotiate for their employees. And 
you'll have more than one choice, so that companies will have to 
compete for your business instead of the other way around.
  Landmark reforms--Social Security, Medicare, Medicaid--these things 
do not come easily. We were sent to Congress this year to do what is 
difficult. Despite the efforts of some shrill voices, we are on the 
verge of overcoming the special interests that halted reform more than 
a decade ago, to deliver on landmark legislation that will make a 
positive difference in the life of every American. It is an historical 
moment, an essential investment in our nation's long-term fiscal and 
economic well-being, and it's long overdue. I urge my colleagues to 
vote yes on the Affordable Health Care for America Act.
  Mr. BACA. Mr. Speaker, today is a historic day for all of us.
  As Members of Congress, it is our duty to pass real healthcare reform 
this year.
  The American people are suffering.
  47 million people lack even the most basic care, and for those lucky 
to have insurance--their premiums have more than doubled over the last 
10 years.
  Perhaps no state is in greater need of this reform than my home state 
of California.

[[Page 27488]]

  217 thousand people in my Congressional District go everyday without 
insurance.
  And for California as a whole--we have 13 million uninsured 
residents.
  The people of California, and people across the United States need 
health care reform that: ends discrimination based on pre-existing 
conditions; ends dropped healthcare coverage because you get sick; ends 
co-pays for preventative care; and ends skyrocketing costs for 
individuals and families.
  The Republican alternative does none of these things.
  It simply keeps the status quo! It does nothing to provide quality, 
affordable health care to the American people.
  The 217,000 people living in my District without insurance cannot 
afford inaction any longer.
  The 13 million people in California without insurance cannot live 
with the status quo.
  The 15 hundred families in my District who went bankrupt because of 
health costs cannot afford the status quo.
  Now is our opportunity to make history--and to move America forward.
  We must not be short-sighted and focus only on politics and polls.
  As a Christian--my faith teaches me we must love and care for our 
fellow man, as if they were our brother or sister.
  I know that fixing our broken health care system is not just an 
economic issue--it is also a humanitarian and a moral issue.
  I am especially pleased that today's bill includes the Indian Health 
Care Improvement Act.
  As a Member of the House Native American Caucus and the Natural 
Resources Committee--I have been a strong supporter of ending the 
health disparities that exist on our reservations.
  I will close my statement by again stressing the importance of this 
historic moment.
  We passed Social Security in 1935. We passed Medicare in 1965.
  I urge my colleagues to stand with the American people and pass 
legislation in 2009 that will make quality, affordable health care a 
right for all Americans.
  Mr. LANCE. Mr. Speaker, this evening members of the U.S. House of 
Representatives are being asked to vote on legislation that 
dramatically revamps our Nation's health care system.
  This 2,000-plus page, $1.3 trillion Democratic health care proposal 
is a measure that raises individual and business taxes and reduces 
funding for Medicare.
  H.R. 3962 increases spending by more than $1 trillion at a time when 
our levels of debt and deficits are at all-time highs.
  The bill imposes a 5.4 percent ``surtax'' on thousands of individuals 
and families in my congressional district during an economic recession 
and when New Jerseyeans are paying some of the highest federal, state 
and local property taxes in the country.
  The health care bill levies at 2.5 percent tax on the Garden State's 
medical device industry that employs more than 300,000 in New Jersey 
alone at a time when New Jersey's unemployment rate is nearly 10 
percent.
  The measure ignores common-sense malpractice reforms while cutting 
Medicare by nearly $500 billion leading the Medical Society of New 
Jersey and its doctors and medical professionals to come out in 
opposition to H.R. 3962.
  In short, this bill, If signed into law, will be harmful to New 
Jersey's taxpayers, seniors and businesses. As such, I rise in strong 
opposition to this measure.
  But make no mistake--I support health care reform.
  Like the majority of my colleagues I strongly support health care 
reform. But not the reform we will be voting on this evening.
  I stand in support of common sense steps to broaden health care 
access and responsible solutions that address the rising cost of health 
care.
  I believe reform ought to include portability--allowing people to 
keep their health insurance whether they change jobs or move to a 
different state. And no one should be denied coverage for preexisting 
conditions.
  Yet the call for common sense health care reform should be one that 
our Nation can afford.
  The Republican substitute offered by House Republican Leader John 
Boehner is a fiscally responsible alternative health care reform 
measure that reduces costs and expands insurance coverage without 
raising taxes, rationing care or putting the government between patient 
and doctor.
  The Republican reform bill includes medical liability reform that 
will seek to end junk lawsuits that force doctors to practice defensive 
medicine driving up health care costs.
  The GOP alternative will allow families and businesses buy health 
insurance across state lines while also allowing individuals, small 
businesses and trade associations to pool together and purchase health 
insurance at lower prices.
  It levies no taxes on New Jersey's medical device industry and 
includes important safety provisions concerning innovative biologic 
drugs by requiring research and clinical trials before the Food and 
Drug Administration can approve generic biologics.
  To maximize safety, I believe that research and those clinical trials 
should be conducted within the United States. By creating this process 
for approval of innovative biologic drugs we protect the health and 
safety of patients, lower health care costs and provide adequate 
incentives for innovation to ensure that New Jersey continues to be the 
``Medicine Chest of the World.''
  These are ideas that have strong, bipartisan support but most are 
absent from the Democrats' new reform legislation.
  Instead of focusing on fiscally responsible reforms that have 
bipartisan support, the Democratic Leadership has chosen a path that 
ignores good ideas from the Republican side of the aisle.
  The Republican substitute is the only health care reform measure that 
improves what is working in our health care system and fixes what is 
broken in a fiscally responsible manner without raising taxes or 
increasing our ever-growing debt and deficit.
  Mr. WILSON of South Carolina. Mr. Speaker, I have criticized many of 
the provisions of this bill (H.R. 3962) and rightfully so. But in 
fairness, I do believe the sections relating to the creation of a 
market for biosimilar products is one area of the bill that strikes the 
appropriate balance in providing lower cost options to consumers 
without destroying a healthy and functioning industry in this country. 
These provisions were one of the few areas in the bill adopted on an 
overwhelming bi-partisan vote for the Eshoo-Inslee-Barton (EIB) 
amendment in the Energy and Commerce Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and at the same time providing a safe and effective way to 
bring competition to benefit patients is a laudable achievement. I wish 
we could remove this provision from this fatally flawed piece of 
legislation and consider it separately because it would pass with the 
kind of overwhelming bi-partisan support that Americans across the 
country wish to see.
  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country. 
Unfortunately, many of the largest companies that would seek to enter 
the biosimilar market have made their money by outsourcing their 
research to foreign countries like India. With this weeks devastating 
news that unemployment has reached 10.2 percent it is critical that we 
preserve jobs in the United States. While the innovator's have created 
jobs here, these generic companies have shipped them overseas, so they 
can turn around and sell cheap knockoffs of innovative American 
products.
  As this new market launches in the U.S., we need to ensure that we 
foster innovative products in this country for the creation of jobs and 
research that will go into proving whether these products are 
interchangeable with the innovators products. I have my doubts that 
these companies can create such interchangeable products, but I am 
certain that the research and testing of whether or not they can should 
occur in this country and not somewhere across the globe. Testing and 
research on these interchangeable biosimilars should occur in this 
country to ensure that it is done properly and safely and to benefit 
our economy.
  Mr. SMITH of Texas. Mr. Speaker, although the Democratic Leadership 
has had several months to address the concerns voiced by countless 
Americans, the latest health care reform bill is no better than the 
last.
  I support health care reform; however, this bill goes far beyond 
fixing the problems we all know need to be addressed and it fails to 
enact true health care reform.
  Skyrocketing costs have crept into our health care system, creating 
uncertainty about the future of health care for employers, working 
Americans, and the uninsured. Americans need more, not fewer, choices 
for something as important and personal as health care.
  Americans are concerned with cost, choice, quality and access of 
health care and Congress should work to address these concerns. Any 
legislation considered should attempt to

[[Page 27489]]

make our health care system more accountable and accessible to 
patients.
  This legislation expands coverage with a government takeover of the 
health care industry funded by new taxes and massive cuts to Medicare.
  The nonpartisan Congressional Budget Office and Joint Committee on 
Taxation estimate that H.R. 3962 would require over $550 billion in new 
taxes on individuals and small businesses.
  CBO also estimates that this legislation will lead to $33 billion in 
penalties for uninsured individuals and $135 billion in penalties for 
employers under the government mandate or ``pay or play'' requirements.
  Raising income taxes on hard-working Americans and threatening small 
businesses with penalties to fund a government takeover of health care 
is a terrible prescription for a troubled economy.
  In order to pay for this government takeover of health care, 
Democrats also have proposed cutting more than $500 billion in Medicare 
spending. The plan also includes an expansion of Medicaid that will 
cost cash-strapped States $34 billion over the next 10 years.
  I believe Congress should pursue reform in terms of costs and access, 
but the legislation advanced by Democratic leaders is equal parts 
faulty premise and flawed logic. Their legislation will increase health 
care spending, limit choice, and cut Medicare benefits.
  The current health care proposal being considered by Congress will 
lead to higher costs, rationing of care, higher taxes on families and 
small businesses, elimination of jobs through punitive taxes on small 
businesses, granting of unchecked power to a new ``health care choices 
commissioner,'' elimination of choices for patients, tax-payer funded 
abortions and a government panel placed between doctors and patients.
  Americans deserve the freedom to choose the type of health care that 
is best for them and their families.
  During his campaign, then-Senator Obama promised that he would ``have 
all the negotiations around a big table'' and ``televised on C-SPAN'' 
to ``allow people to stay involved in this process.'' Yet the 
negotiations and decisionmaking process have taken place behind closed 
doors with the media and American people shut out.
  That is why the bill lacks bipartisan support. In fact, there is 
bipartisan opposition to the House Democrats' government take-over.
  Rather than increasing taxes and rationing care, the President needs 
to address medical liability reform, which is one of the biggest 
sources of waste and added cost.
  Frivolous lawsuits force physicians to practice defensive medicine 
and carry expensive malpractice insurance, the cost of which is passed 
on to patients. Uncapped lawsuit awards paid by insurance companies 
also get passed on to patients as higher premiums.
  It is a disservice to the American people that this legislation fails 
to include the legal reforms that are necessary to make any expansion 
of health care coverage financially sound.
  Unlimited lawsuits enrich trial lawyers while increasing the cost of 
health care for everyone. Unfortunately, we now know that opposition by 
trial lawyers is the reason tort reform has been excluded from all the 
Democrats' health care proposals, including the one we will be voting 
on today. Former Democratic National Committee Chairman Howard Dean 
said the following publicly at a recent town hall meeting: ``[T]he 
reason why tort reform is not in the bill is because the people who 
wrote it did not want to take on the trial lawyers . . . and that is 
the plain and simple truth.''
  That political opposition, which Governor Dean admitted is not based 
on the merits but on raw self-interest, flies in the face of the facts.
  The CBO estimates that enacting tort reforms nationwide would result 
in a reduction of medical malpractice insurance rates by 25 percent to 
30 percent. And according to the Government Accountability Office, 
rising litigation awards are responsible for skyrocketing medical 
professional liability premiums.
  Lower premiums mean Americans will pay less to have better health 
care.
  The President of the American Medical Association said ``If the 
[health care] bill doesn't have medical liability reform in it, then we 
don't see how it is going to be successful in controlling costs.''
  And the President's own doctor of over two decades supports tort 
reform. He said regretfully that ``I once briefly talked to [the 
President] about malpractice, and he took the lawyers' position.''
  In the handful of States that have enacted tort reform, health care 
costs have fallen, and the availability of medical care has expanded. 
In my home State of Texas, premiums fell by 30 percent, and more than 
14,000 doctors returned or set up new practices in the state.
  To give just one example, a charitable hospital group in Texas that 
serves the poor and underserved reported that since Texas enacted tort 
reform, its legal costs have gone from $153 million per year to just 
$2.3 million last year.
  Doctors are so concerned about frivolous lawsuits that they order 
unnecessary--and expensive--tests and procedures that are of no benefit 
to the patient.
  HHS estimates the national cost of defensive medicine is more than 
$60 billion. The Congressional Budget Office just issued a report that 
concludes it costs $54 billion. The costs of litigation and defensive 
medicine are then passed off to the patient in the price of health 
care.
  If tort reform were enacted, trial lawyers would stand to lose one of 
their primary sources of income: medical malpractice suits, which are 
often just a form of legalized extortion. But all Americans would gain, 
and tens of billions of dollars would suddenly be freed up and could be 
used to help provide health insurance to the uninsured.
  Regrettably, the Democrats' health care bill not only fails to 
contain any of the tort reforms the CBO concluded would save at least 
$54 billion in health care costs, but also contains a provision that 
bribes States with Federal taxpayer dollars not to enact such reforms 
in the future. It explicitly prohibits tort reform ``demonstration 
project'' funds from going to States that put limits on damages or 
attorneys' fees.
  Section 2531 of the Democrats' bill states that ``the Secretary [of 
HHS] shall make an incentive payment . . . to each State that has an 
alternative medical liability law in compliance with this section,'' 
but then goes on to say a state can take advantage of such funds only 
if ``the law does not limit attorneys'' fees or impose caps on 
damages,'' which are exactly the tort reforms the CBO concluded yield 
real health care costs savings.
  That is not only a blow to State reform efforts. It is a federally 
funded bribe discouraging states from enacting real reform and a giant 
bailout for trial lawyers.
  H.R. 3962 also contains two antitrust provisions that are within the 
House Judiciary Committee's jurisdiction: Sec. 262, which repeals the 
McCarran-Ferguson Act for health and medical malpractice insurers, and 
Sec. 2573, which codifies a ban on settlements between name brand and 
generic pharmaceutical manufacturers in the context of Hatch-Waxman 
litigation. Neither provision was given due consideration in the 
Judiciary Committee, and their unintended consequences could have 
significant negative impacts on the cost and availability' of both 
insurance and medications.
  My basic concerns with Sec. 262 are its breadth, the possible 
unintended consequences, and the fact that the provision will do no 
good and may do much harm. For more than 60 years, the States have 
regulated the business of insurance and built a record that provides 
guidance about permissible activity. By inviting Federal intervention, 
this bill creates a dual regulatory system that only confuses the 
health insurance and medical malpractice industry.
  The bill presents a wholesale repeal of McCarran-Ferguson for health 
insurers and medical malpractice insurers. Further, the protections for 
information gathering by a State insurance commission or other State 
regulatory entity that were included in the similar bill (H.R. 3596) 
reported by the Judiciary Committee over my opposition have been 
completely eliminated from the legislation.
  The uncertainty caused by this provision threatens small and large 
insurers alike, but the smaller ones that depend on sharing 
information, under oversight by State regulators, are most at risk. 
Thus the bill threatens to reduce competition among health and medical 
malpractice insurers. With no demonstrable benefits and many potential 
adverse effects, Sec. 262 should not have been included in the bill.
  Section 2573 raises different concerns. When a generic drug 
manufacturer files an Abbreviated New Drug Application under the Hatch-
Waxman Act with the Food and Drug Administration, it indicates its 
intention to infringe on a brand manufacturer's patent. This means that 
the generic company is trying to enter into the brand manufacturer's 
drug market before the branded pharmaceutical's existing patent has 
expired. This notice usually results in a lawsuit by the brand company 
that leads to a settlement about the date on which the generic 
manufacturer can begin selling a generic version of the branded 
company's drug. This is nothing new. Most cases in the United States, 
whether civil or criminal, antitrust or patent, settle. The reasons for 
this are simple: litigation is expensive and its outcomes are 
uncertain.
  The supposed problem is when a settlement in the Hatch-Waxman context 
involves a payment in lieu of or in addition to an agreement

[[Page 27490]]

on the date of entry into the market by the generic manufacturer. Such 
payments are said to frustrate the intent of Hatch-Waxman by allowing 
the brand company to ``pay to delay'' entry of the generic competitor.
  The proposed solution to this problem, incorporated in Sec. 2573, 
goes too far. The bill calls for a ban on all Hatch-Waxman settlements 
that feature any consideration, such as cash or an exchange of patents, 
in addition to the date of entry. Such a ban dramatically reduces the 
ability of companies to settle these cases. After all, if the parties 
could not agree on date of entry, then they would effectively be forced 
to litigate the case to the bitter end. This means that, in some cases, 
a settlement would have resulted in generic entry into that particular 
drug market much earlier than if the brand company wins its patent 
suit.
  I fear this ban will itself frustrate the intent of Hatch-Waxman by 
limiting the incentives for generics to challenge these patents and for 
brand companies to innovate.
  The best way to reach the appropriate balance is through a case-by-
case analysis by a neutral third party of the competitive effects of 
these settlements using the rule of reason. This, in essence, is the 
conclusion that the majority of the Courts of Appeals, including the 
Second, Eleventh, and DC Circuits, have reached in these cases, and we 
should uphold the judgment of these courts.
  The only saving grace of Sec. 2573 is that it creates a cause of 
action separate and apart from the antitrust laws and will not affect 
how those laws are interpreted in the future. This also means that the 
provision, as written, did not come before the Judiciary Committee, 
even though it remains, at heart, a competition issue. By keeping the 
Judiciary Committee from considering this legislation, we are 
eliminating the incentives for drug invention and generic competition 
that have served American consumers so well. Innovative new drugs, 
after all, are created in the laboratory, not the courtroom.
  Sec. 1640 of the bill also contains a provision that allows the 
Department of Health and Human Services to issue administrative 
subpoenas to insurance companies during investigations of decisions to 
exclude benefits. The standard for issuing an administrative subpoena 
under the bill is extremely low. The information sought must simply 
``relate to'' the matter under investigation.
  It is highly ironic that we are considering this bill with this 
administrative subpoena language during the same week the Judiciary 
Committee approved the Democrats' revision of the FBI's authority to 
issue National Security Letters, which are the functional equivalent of 
administrative subpoenas used in foreign intelligence and terrorism 
investigations.
  The Democrats' bill reported this week by the Judiciary Committee 
replaces the current ``relevance'' standard for issuing a National 
Security Letter with a heightened standard, requiring the FBI to show 
``specific and articulable facts'' in order to seek particular 
information using a National Security Letter. House Democrats want to 
make it easier for the government to investigate insurance companies 
than to investigate terrorists plotting to kill Americans.
  In the end, this 1,990-page bill will raise premiums and health care 
costs on all Americans. It imposes mandates and new taxes on the middle 
class and small businesses. It fails to address tort reform and it 
dumps a huge unfunded expansion of Medicaid on the states. Combined 
with budget gimmicks to hide $245 billion in costs and massive cuts to 
senior benefits, this is simply bad medicine.
  Mr. MORAN of Kansas. Mr. Speaker, after reviewing H.R. 3962, the 
Affordable Health Care for America Act, listening to the concerns of 
Kansans, and visiting Kansas hospitals to speak with doctors, nurses, 
patients, and administrators, I have concluded that this bill will be 
harmful to Kansas and I strongly oppose it. However, I do believe the 
sections relating to the creation of a market for biosimilar products 
is one area of the bill that strikes the appropriate balance in 
providing lower cost options to patients without destroying a healthy 
and functioning industry in this country. These provisions were one of 
the few areas in the bill adopted on an overwhelming bipartisan vote 
for the Eshoo-Inslee-Barton, EIB amendment in the House Energy and 
Commerce Committee.
  Creating a pathway for new products that does not destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and, at the same time providing a safe and effective way 
to bring competition to benefit patients and encourage treatments, is a 
necessary objective. New biosimilars have the potential to 
fundamentally change the course of many diseases. We need to promote 
patient safety and ensure incentives to encourage the continued 
development of a critical weapon to fight diseases such as Alzheimer's, 
Parkinson's and cancer. I wish we could remove these specific 
provisions from H.R. 3962 and consider them separately because it would 
most likely pass with the kind of overwhelming bipartisan support.
  However, these provisions are only the first step in a long path to 
the marketing of these new biosimilar products. New research and 
clinical testing will have to occur and the FDA will implement 
regulations that will ensure this research is done safely and 
effectively. Biopharmaceuticals represent a tremendous growth 
opportunity for our burgeoning bioscience industry in Kansas, and we 
need to work to see that new biotechnology products continue to reach 
patients and medical professionals.
  As this new biosimilar market develops in the United States, we need 
to ensure that we foster innovative products in this country for the 
creation of jobs and research that will go into determining whether 
these products are interchangeable with the innovator's products. 
Testing and research on these interchangeable biosimilar products 
should occur in this country to ensure that it is done properly and 
safely and to benefit our patients and our economy.
  Ms. GRANGER. Mr. Speaker, I have criticized the majority of the 
provisions in H.R. 3962, the Affordable Health Care for America Act, 
and I will vote against it. However, I am pleased that H.R. 3962, as 
well as the Republican Substitute Amendment that I support, both 
include language relating to biosimilar products.
  The provisions related to the creation of a market for biosimilar 
products is one area of the bill that strikes the appropriate balance 
in providing lower cost options to consumers without destroying a 
healthy and functioning industry in this country. These provisions were 
one of the few areas in the bill adopted in a bipartisan vote for the 
Eshoo-Inslee-Barton amendment in the Energy and Commerce Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and at the same time providing a safe and effective way to 
bring competition to benefit patients is a laudable achievement. I wish 
we could remove this provision from this bill so that I could vote for 
it on its own. I believe that if this provision was considered on its 
own it would pass the House of Representatives with bipartisan support.
  The biosimilar provisions in this bill are only the first step in a 
long path to the marketing of these new products. New research and 
clinical testing will have to occur and the FDA will write rules that 
will ensure this research is done safely and effectively.
  One of the reasons I have long supported the U.S. biotechnology 
industry is that it is a homegrown success story that has been an 
engine of job creation in this country. With this week's news that 
unemployment has reached 10.2 percent, it is critical that we preserve 
jobs in the United States. Testing and research on these generic 
biosimilars should take place in the United States to ensure that it is 
done properly and safely while benefitting our economy.
  Innovative biotechnology companies have created jobs here in the 
United States and we must continue to support them.
  Mr. PAYNE. Mr. Speaker, I an others have spoken at length on the ways 
that this bill will improve health care for all of our constituents. 
Another significant benefit of this legislation which has not received 
as much attention will be the creation of new high-paying jobs in this 
country. Let me repeat that for some of my friends on the other side of 
the aisle, this bill will create high-paying, high-quality jobs in 
healthcare delivery, technology and research in the United States.
  First, this bill will create enormous demand for healthcare workers, 
especially in the area of primary care. Insuring the millions of 
Americans in this country who currently have no insurance will allow 
them to see primary care providers and receive the wellness and 
preventive care they have been denied for too long. This influx of new 
patients will need doctors, nurses and technicians for their care, 
while reducing overall healthcare costs because they will not need much 
more expensive hospitalizations. I support channeling resources that 
for too long have been used to treat people once they become sick into 
jobs and services that will prevent people from getting sick in the 
first place.
  Second, this bill will continue the efforts we began in the stimulus 
package to deploy new health information technologies that better 
manage both the quality of care people receive and the cost at which 
they receive it. New health care exchanges and new demands on the 
health system to provide high-quality and cost-effective health care 
will create new opportunities and markets for our

[[Page 27491]]

brightest technology minds. They will be incentivized to create and 
develop products that will be a win/win for Americans: high quality 
health care at an affordable price.
  Third, this bill will create high quality research opportunities in 
this country. The Energy and Commerce Committee enacted a framework for 
allowing biosimilar competition in this country. This new class of 
medicines will help lower costs and bring competition to one area that 
is key to the future of our healthcare system. Biotechnology is on the 
cutting edge of efforts to reducing costly invasive procedures and 
allowing our constituents to live healthier and more productive lives. 
The creation of this new class of medicines comes with requirements for 
new clinical research and testing, especially in the area of whether a 
new biosimilar can be interchangeable with an innovator's product. This 
research will create high quality and high paying jobs and it is 
imperative that we keep this research and these jobs in this country.
  We cannot allow these research opportunities to leave this country, 
and I intend to work with the Secretary of HHS and the Commissioner of 
the FDA to ensure they stay in the United States.
  I do not look at this bill as one of cost or drain on the economy of 
our country like so many of its opponents on the other side of the 
aisle. I see this bill as an exciting opportunity to create the kind of 
jobs we so desperately need in this country while at the same time 
improving the lives of ALL Americans. This bill will improve health 
care, create jobs and grow our economy.
  Mr. TERRY. Mr. Speaker, I have criticized many of the provisions of 
this bill and rightfully so. But in fairness, I do believe the sections 
relating to the creation of a market for biosimilar products is one 
area of the bill that strikes the appropriate balance in providing 
lower cost options to consumers without destroying a healthy and 
functioning industry in this country. These provisions were one of the 
few areas in the bill adopted on an overwhelming bi-partisan vote for 
the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce 
Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and at the same time providing a safe and effective way to 
bring competition to benefit patients is a laudable achievement. I wish 
we could remove this provision from this fatally flawed piece of 
legislation and consider it separately because it would pass with the 
kind of overwhelming bi-partisan support that Americans across the 
country wish to see.
  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country.
  As this new market launches in the United States, we need to ensure 
that we foster innovation and ensure the safety of any new product 
brought to the market.
  Ms. CLARKE. Mr. Speaker, I support this legislation because it 
eliminates gender rating that allows young women to be charged 45% more 
than men for identical coverage.
  Mr. POE of Texas. Mr. Speaker, H.R. 3962 forces businesses and 
individuals to purchase health insurance. It raises at least two 
constitutional issues. Congress should never pass an unconstitutional 
bill, and I will vote against H.R. 3962.
  The Constitution doesn't give the Federal Government direct authority 
to compel the purchase of health insurance. The Supreme Court would 
once again have to come in and by judicial edict give the government 
the intrusive power to do what it obviously cannot do now: stretch the 
meaning of the Commerce Clause.
  Can the Federal Government force people to buy health insurance 
whether they can afford it or not? Can the Federal Government then 
impose a criminal fine on them under the guise of calling it a tax if 
they fail to buy the insurance?
  What happens if the citizen doesn't pay the fine? Do they go to jail 
without the benefit of trial by jury? Do they lose their right to 
confront witnesses and have a lawyer?
  Congress forcing mandatory health insurance on Americans and then 
imposing criminal sanctions without due process is a violation of the 
Constitution. This action would shock the Framers of our Constitution.
  These serious constitutional issues cannot be ignored and I strongly 
oppose H.R. 3962 and any other bill that violates our Constitution.
  Mr. Speaker, I am strongly against H.R. 3962, and I will vote against 
it should it come to a vote on the House floor. However, I do believe 
the sections relating to the creation of a market for biosimilar 
products is one area of the bill that strikes the appropriate balance 
in providing lower cost options to consumers without destroying a 
healthy and functioning industry in this country. These provisions were 
one of the few areas in the bill adopted on an overwhelming bipartisan 
vote for the Eshoo-Inslee-Barton (EIB) amendment in the Energy and 
Commerce Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and at the same time providing a safe and effective way to 
bring competition to benefit patients is a laudable achievement. I wish 
we could remove this provision from this fatally flawed piece of 
legislation and consider it separately because it would pass with the 
kind of overwhelming bi-partisan support that Americans across the 
country wish to see.
  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country. 
Unfortunately, many of the largest companies that would seek to enter 
the biosimilar market have made their money by outsourcing their 
research to foreign countries like India. With this week's devastating 
news that unemployment has reached 10.2% it is critical that we 
preserve jobs in the United States. While the innovators, have created 
jobs here, these generic companies have shipped them overseas, so they 
can turn around and sell cheap knockoffs of innovative American 
products.
  As this new market launches in the U.S., we need to ensure that we 
foster innovative products in this country for the creation of jobs and 
research that will go into proving whether these products are 
interchangeable with the innovators products. I have my doubts that 
these companies can create such interchangeable products, but I am 
certain that the research and testing of whether or not they can should 
occur in this country and not somewhere across the globe. Testing and 
research on these interchangeable biosimilars should occur in this 
country to ensure that it is done properly and safely and to benefit 
our economy.
  Mr. KIRK. Mr. Speaker, our goal in health care reform should be to 
lower the cost of health care, making it more affordable for Americans 
to purchase coverage. Many young adults from Illinois and elsewhere 
will be hit very hard under this legislation if they do not have 
coverage provided by their employers. We should not force young 
Americans to purchase coverage that costs them more because of reform. 
This is a new expensive tax targeted to young workers--and I oppose it.
  According to the Department of Health and Human Services, 29 percent 
of individuals between the ages of 18 and 24 are uninsured and 27 
percent of individuals between the ages of 25 and 34 are uninsured. 
Prices in the individual insurance market are already so high they do 
not think it is worth it. The misnamed ``Affordable Health Care Act'' 
that we are debating now will make this coverage even more expensive.
  The reason is that this bill requires that insurers may not charge 
64-year-olds more than twice what they charge healthy 19-year-olds. 
This mandate will raise premiums on young adults tremendously. Young, 
healthy people who lack coverage, mostly because they find it too 
expensive at a current cost of $1,700 to $2,000 for it, will be forced 
to buy policies that cost $3,000, even after federal subsidies. The 
House bill's ``age rating'' of 2 to 1 is far below the 5 to 1 ratio 
currently prevalent in the insurance market. Why does this ratio exist? 
Simply because the medical bills of healthy young people are a fraction 
of what older Americans spend. Comparisons of the House bill with an 
estimate of what is available on the individual market now using data 
provided by the Kaiser Family Foundation demonstrate that a 25-year-old 
single individual making $30,000 will pay a premium of $3,169 under the 
House bill after subsidies, while similar standards with a 4:1 age 
rating cost $2,258. It is almost a $1,000+ leap. This is a big deal for 
those earning only $30,000.
  The Kaiser Family Foundation provides a way to estimate how insurance 
premiums will rise for young workers and their families:

------------------------------------------------------------------------
                                           House     Current     Higher
                                Salary      bill      market    premium
------------------------------------------------------------------------
Single Policy:
    21......................    $30,000     $2,724     $2,258       $466
    25......................    $35,000     $3,169     $2,258       $911

[[Page 27492]]

 
    28......................    $40,000     $3,169     $2,435       $734
    30......................    $42,000     $3,169     $2,676       $493
Family of Four:
    28......................    $75,000     $8,102     $7,402       $700
    30......................    $90,000     $8,543     $7,862       $681
------------------------------------------------------------------------

  I proposed an amendment to this bill that would ensure that anyone 
purchasing insurance coverage after January 1, 2013 is exempt from the 
individual mandate if a less expensive insurance plan than those 
available under today's bill Act was available six months prior to its 
enactment. Unfortunately, this amendment was not made in order by the 
Rules Committee.
  In health care reform, we should do no harm. We must enact reforms 
that will actually lower the costs of insurance premiums so Americans 
can afford to purchase coverage. Enacting a bill that makes it more 
expensive for young workers to buy insurance coverage and then forcing 
them to buy such coverage is wrong.
  In closing, I want to commend Shauna McCarthy of my staff for the 
many months she has committed to health reform, contributing to this 
amendment as well as the Medical Rights and Reform Act, which seeks to 
prevent government intervention in the important relationship between 
patients and their doctors.
  Mrs. MALONEY. Mr. Speaker, Sunday, 42,000 people gathered in my 
hometown of New York City to run the NYC marathon while 2 million more 
people watched, cheered, and marveled at those who accepted the 
challenge of running 26.2 miles. It is likely that each participant had 
a different reason for running, but the ultimate goal was the same: to 
finish, to succeed, and to accomplish a goal. As Greek legend explains, 
the concept of the marathon comes from the long distance a messenger 
ran to deliver the important news that the battle had been won. Mr. 
Speaker, as we stand here today to debate a historical bill that will 
substantially improve the delivery of health care in America, we are 
the runners at mile 25. The cheers are the loudest, the anticipation is 
the greatest, and the end, while near, seems very far away. Despite all 
of the noise, the message is clear: now is the time for health care 
reform, now is the time to take care of all Americans, now is the time 
to make sure that families are not forced to see loved ones die because 
they did not get the care they need and deserve.
  I'd like to thank and commend the leadership of Speaker Pelosi, 
Majority Leader Hoyer, Chairmen Waxman, Miller and Rangel and of 
course, Chairman Emeritus Dingell who has been working on health care 
reform since he first came to Congress. H.R. 3962, the Affordable 
Health Care for America Act, is a significant and important step toward 
securing affordable, accessible, and quality health care for all 
Americans. Our current health care system is broken. Costs continue to 
increase at unsustainable rates and too many families and businesses 
are feeling the debilitating burdens brought on by these expenses. Too 
many Americans have inadequate coverage or lack coverage entirely and 
are suffering or dying as a result.
  H.R. 3962 is critical to the health of our families, to the health of 
our economy and to the health of our nation;
  H.R. 3962 lowers costs for every patient, reins in premiums, co-pays, 
and deductibles, limits out of pocket costs, and lifts the cap on the 
amount that insurance companies cover each year;
  H.R. 3962 strengthens Medicare, securing the financial stability and 
solvency of Medicare for years to come, and provides seniors with 
better benefits and guaranteed access to their doctors;
  H.R. 3962 reduces the deficit by over $100 billion in the first 10 
years, and likely by even more in the following decade, according to 
the Congressional Budget Office;
  H.R. 3962 provides affordable coverage to those who cannot get health 
insurance because of pre-existing conditions, including domestic 
violence and pregnancy, and protects consumers from higher rates due to 
gender or other factors;
  And, very importantly, I am proud that H.R. 3962 includes a public 
health insurance option that will increase competition and reform our 
current system. I am grateful to Speaker Pelosi for her steadfast 
support of this important provision and am confident that it will 
expand access to care to the many people in need. When 14,000 Americans 
are losing their health care coverage each day, it is clear that a 
public option is needed. It will bring down costs, increase access, and 
improve care for all Americans. The richest country in the world should 
not have people who go without the basic necessity of health care. The 
public option will hold health insurance companies accountable for the 
practices that price people out of the health care they need and 
deserve.
  Health care is the most important public policy issue of our 
generation that will affect generations to come. I am grateful for the 
opportunity to be a part of this momentous reform and would like to 
take the time to highlight some areas of the bill that specifically 
impact my Congressional district.
  H.R. 3962 will improve employer-based coverage for 440,000 residents 
in my district and will provide credits to help pay for coverage for up 
to 120,000 households. It will also improve Medicare for 88,000 
beneficiaries, including closing the prescription drug donut hole for 
8,100 seniors. H.R. 3962 will allow 33,300 small businesses to obtain 
affordable health care coverage and provide tax credits to help reduce 
health insurance costs for up to 31,300 small businesses and will cover 
26,000 uninsured residents. In short, H.R. 3962 will make health care 
affordable for the middle class, provide security for seniors, and will 
guarantee access to health insurance coverage for the uninsured while 
reducing the federal deficit over the next ten years and beyond.
  In addition to representing the residents of the 14th Congressional 
District of New York, I am proud to represent 14 hospitals. Many of 
these are the jewels of American medicine, training our nations' 
doctors, and facilitating cutting edge research that identifies cures 
and gives hope to millions of Americans and their families. I am 
pleased that H.R. 3962 recognizes the importance of teaching hospitals 
and preserves Graduate Medical Education. New York's teaching 
hospitals, while training our future physicians, are treating the 
sickest of the sick and poorest of the poor. These payments, including 
Direct Medical Education and Indirect Medical Education are critical to 
the survival of these hospitals and to the greater good of medicine.
  H.R. 3962 takes into account diverse patient populations, the cost of 
goods and services, and the higher costs incurred by teaching 
hospitals. Teaching hospitals tend to treat the most complex cases and 
are the first to adopt innovative technologies and techniques that 
advance patient outcomes, so their costs are often higher than average. 
A policy that reduces spending arbitrarily runs the risk of stifling 
innovation which is why I am pleased that the bill is sensible on how 
it addresses geographic variation. This bill recognizes the pitfalls of 
a blanket overhaul. It requires the Secretary of HHS to contract with 
the Institute of Medicine to conduct two studies. The first is a study 
of wage levels which will look at the hospital wage index and the 
physician geographic practice cost index and will recommend changes to 
the methodologies, if necessary. The second study looks at the 
geographic variation associated with volume and intensity of services 
in Medicare, Medicaid, and private sector spending per capita. The IOM 
is encouraged to understand and separate out higher-than-average 
spending due to unavoidable or desirable factors (e.g., patient 
demographic and clinical risk factors and wage levels) from higher-than 
average spending due to avoidable or undesirable factors (e.g., 
excessive medical errors, and practice patterns differing from best 
practices). The bill wisely includes specific prohibitions against 
recommendations to reduce graduate medical education, disproportionate 
share, and health information technology payments.
  While I am pleased with the bulk of the bill, I am concerned that 
H.R. 3962 does not extend the 340B discounts to drugs purchased for 
inpatient use, a provision that was included in an earlier version of 
the bill. Currently, the 340B Drug Pricing Program requires 
pharmaceutical manufacturers that participate in Medicaid to sell 
outpatient drugs at discounted prices to disproportionate share 
hospitals (DSH) that serve a high threshold of low-income, uninsured 
and underinsured patients. Under current law, DSH hospitals 
participating in the 340B Drug Pricing Program pay approximately thirty 
percent more for their inpatient drugs than their outpatient drugs, 
although the drugs are frequently the same. The inpatient and 
outpatient settings serve the same low-income population that the 340B 
Drug Pricing Program was designed to assist. These discounts lower 
costs for patients and taxpayers. At a minimum, extending the 340B Drug 
Pricing Program to inpatient drugs would reduce inpatient drug costs by 
fifteen percent. These new resources could be better used to provide 
direct patient care. I am hopeful that during Conference, the House 
will cede to the Senate language and extend the 340B drug pricing to 
inpatient drugs. After all, now is not the time to deprive safety net 
hospitals from millions of dollars in savings needed to treat the most 
vulnerable in our communities.
  Mr. Speaker, the task is huge and the rewards even bigger. Today we 
will vote to cover 96 percent of Americans without adding a dime to the 
deficit. We will be doing what's right for our families, what's right 
for our economy, and what's right for our future. I urge my

[[Page 27493]]

colleagues to look at the larger picture and remember that today we 
will make a lasting difference in people's lives.
  Mr. TERRY. Mr. Speaker, I rise today to make the House aware of a 
seemingly silent crisis facing millions of Americans and to offer a 
potential solution. I am talking about the problem of personal medical 
debt, and the critical need for medical debt counseling. As a result, 
thousands of Americans in my state of Nebraska and throughout our 
nation are facing extremely difficult choices that severely impact 
their quality of life, and sometimes life itself.
  Mr. Speaker, I am sure my colleagues are aware that medical debt is 
the number one cause of personal bankruptcy in this country. Let me say 
that again: 60 percent of all personal bankruptcies are the result of 
crushing medical debt. I know that my colleagues would agree that this 
is an astonishing, and indeed, an embarrassing statistic for our 
country.
  In most cases, those who suffer from serious medical debt are people 
with chronic diseases who have just enough insurance to be considered 
insured. While they may technically be insured, the fact of the matter 
is that in reality they are severely underinsured. Simply put, they are 
faced with some extremely difficult choices between whether to pay 
their medical bills or pay for their basic needs. For example, someone 
with a chronic disease who is saddled with extremely high medical debt 
may have to choose between paying their mortgage or putting food on the 
table and paying the bill for life-saving treatments for their disease.
  It is not hard to understand that when faced with these kinds of 
options more than half the time people chose to declare bankruptcy. 
That means that hospitals take a loss, individuals who have declared 
bankruptcy ruin their credit, and the American people in the end 
typically pay for it all.
  Mr. Speaker and my colleagues, we can help fix this crisis with 
medical debt counseling.
  The idea behind medical debt counseling is simple: Create a network 
of non-profit organizations that provide counseling services 
specifically for medical debt. The nonprofit counselors will provide 
the participants with a number of options long before the idea of 
bankruptcy is even considered. This is a win-win for everyone. A person 
can avoid bankruptcy, and a health care provider such as a hospital or 
doctor, can receive payment for their services.
  Nonprofit organizations with expertise in helping under-insured 
people with chronic diseases manage their burden, such as the Chronic 
Disease Fund which assists people in my state, should be put on the 
front lines of providing effective medical debt counseling. They are 
the experts which are best equipped to provide effective counseling so 
that individuals will not be forced into declaring bankruptcy because 
of their medical debt.
  To my knowledge, there is nothing in the pending health care reform 
legislation that would help encourage medical debt counseling. This 
brings me to an important point. Because we have moved so fast on 
health care reform legislation, good ideas like medical debt counseling 
are not part of this bill. We need options like this for health care 
reform because it will work to save the American taxpayer money. 
Medical debt 2 counseling will reduce the cost burden on the health 
care system, not increase it. And medical debt counseling is 
innovative. It is innovation like this that made America's health care 
the best in the world.
  Mr. Speaker, my constituents, like yours, provide for their families 
but they live on a tight budget. When faced with the reality of making 
a huge medical bill payment or putting food on the table, what do you 
think they are going to do? We can help them avoid this terrible 
scenario. Again, 60 percent of bankruptcies in this country are because 
of crushing medical debt. We can help lower the number of personal 
bankruptcies across this great nation, but to do so we need to 
encourage a system of medical debt counseling.
  Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of 
H.R. 3962, Affordable Health Care for America Act, offered by Rep. John 
Dingell of Michigan and ask all of my colleagues to support this 
historic bill before us that will expand coverage to 36 million 
uninsured Americans, ensure that patients and physicians make their own 
health care choices, reduces administrative costs, invests in wellness 
and prevention, reforms the insurance industry by ending discriminatory 
practices, especially pre-existing conditions and health disparities, 
and allows young adults to remain on their parents' insurance policy 
until the age of 27.
  I have held numerous town hall meetings in my district to listen to 
the views of my constituents. My office has received numerous calls, 
emails, and letters on this subject, with an overwhelming majority 
asking me to vote YES on the bill because America cannot wait any 
longer for health care insurance reform. More than 300 groups, 
representing millions of Americans, have expressed their support for 
the bill, including the American Association of Retired Persons, the 
American Cancer Society, the United Auto Workers, the AFL-CIO, the 
SEIU, Families USA and the National Committee to Preserve Social 
Security and Medicare. The groups expressing their support include a 
broad range, including groups representing doctors, seniors, small 
business, youth, women, persons with disabilities, consumers and 
patients.
  Health care insurance reform is not a Republican or Democratic issue, 
it is an American issue. Under a Democratic President, we witnessed the 
beginnings of health care reform with Medicaid and Medicare in the 
1960s. Under another Democratic President, we will witness the second 
coming of true health care reform.
  Today's vote will mark a change in our country where every American 
will know that health care is a top priority for this country. When I 
was a newly elected Member to the U.S. House of Representatives, 
Congress was in the throes of reforming health maintenance 
organizations or HMOs. While this was well intended, at the time, I 
asked, ``what about those millions of people who go to work each and 
every day, who care for our senior citizens in nursing homes, who clean 
our bathrooms, cook our food, clean our streets, and send their 
children to college, but whose employers do not provide health care?'' 
What happened is that those individuals did not have health care 
coverage, period. Now is the time to help those janitors, street 
sweepers, short-order cooks, child care workers, home health care 
providers, and small businesses so that those workers, too, will be 
able to have health care.
  The 111th Congress has taken bold steps to provide more access to 
health care for Americans. While we have expanded health coverage to 
more than five million uninsured children through the passage of the 
State Comprehensive Health Improvement Plan or SCHIP, we must complete 
what we started. Access to health care is vital to the health of not 
only individual Americans but to the American economy.
  Even before our recent economic crisis, health care was getting more 
expensive, what few benefits were offered were eroding, and even more 
people were losing coverage. In 2007, according to various sources, 45 
million Americans were uninsured; this number is an increase over 
2000's 38.7 uninsured Americans. And this is the uninsured; we are not 
even discussing the millions more senior citizens, working poor and 
families who are underinsured. I am talking about seniors who have to 
choose between eating or their prescriptions. I am talking about those 
families who have to choose between taking their child to the doctor or 
food for the week. The economic crisis has only made this situation 
worse.
  The bankruptcy of the automobile industry, the closing of auto 
dealerships, and the crisis faced by automobile suppliers have caused 
thousands more in our Nation and in particular the state of Michigan to 
lose their employee health benefits.
  Our version of health care reform, the Affordable Healthcare for All 
Americans Act, has four key highlights for Americans and American 
businesses: lower costs; greater choice; higher quality and peace of 
mind. As Health and Human Services Secretary Sebelius said earlier, if 
we do nothing to reform health care, we will continue to live sicker, 
die faster and pay twice as much.
  Health care reform legislation should require coverage of the full 
range of women's reproductive health services. H.R. 3962 protects these 
rights and ensures that all women have access to a health care plan 
that meets their needs while respecting current law. The Stupak 
amendment would limit access to reproductive care in the private and 
public options, and does not allow citizens to pay for the procedure 
out of their own pockets. I voted against the Stupak amendment.


        Health care reform will provide lower health care costs

  Under the America's Affordable Health Care Act, there will be no more 
co-pays or deductibles for preventive care. No more rate increases or 
exclusions for pre-existing conditions, gender or occupation. There 
will be an annual cap on the out of pocket expenses for individuals and 
businesses. Finally, for the first time, there will be guaranteed and 
affordable oral, hearing, and vision care for children.
  By having a public health care plan, the bill will ensure competition 
for Americans to have the best health care at the most affordable cost. 
Also, since everyone will have health

[[Page 27494]]

care, no one industry or business will be at an advantage over another 
one.


    Health Care reform will provide greater choice for all Americans

  Americans will be able to keep their doctor, and their current plan, 
if you like what you have. With a high quality public health insurance 
option competing with private insurers, there will be more choice of 
providers and more benefits. The important aspect is this--every 
American will have a choice of providers, versus today's choice, for 
the uninsured, of the emergency room or no care at all. No one will be 
forced into a public option. This will just be one of many choices.


  Health care reform will provide higher quality health care for all 
                        Americans and businesses

  You and your doctor--not insurance companies--will make health care 
decisions. As more primary care, family doctors, and nurses enter the 
workforce, even more access is guaranteed for all Americans. Also, the 
bill mandates coverage for mental health care, a key issue that will 
affect, in particular, the families of our service members who are 
returning from the wars in Iraq and Afghanistan.


             Health care reform will provide peace of mind

  The bill provides a cap on catastrophic coverage--coverage for 
traumatic injuries such as spinal cord injuries and long-term health 
care. There will be no more denial of coverage for preexisting 
conditions, and no reason to make a life or job decision based on 
whether or not you or your family will have health care coverage.
  We need health insurance reform now. Access to quality, affordable 
health care is critical to the well-being of all Michiganders and all 
Americans, today and tomorrow. Central to all of this is addressing the 
needs of uninsured Americans, strengthening our Medicare system, 
providing health insurance to low-income children and families, funding 
research into diseases like diabetes and cancer, and giving patients 
the ability to make decisions with their doctors, not health insurance 
companies. An estimated 1,400 families lose health insurance every day 
that we do not pass health insurance reform.
  One aspect of this legislation of which I am most proud is its fiscal 
responsibility. According to a letter dated November 5, 2009 from the 
non-partisan, objective Congressional Budget Office, this bill adds not 
one dime to the deficit. Furthermore, this bill reduces the deficit by 
an estimated $109 billion. This is not only fiscally responsible, it 
allows us to provide health care to the least of our sisters and 
brothers.
  When this bill is signed into law, ten provisions of the bill will 
take effect immediately:
  It will begin to close the Medicare Part D ``Donut'' Hole. The bill 
reduces the donut hole by $500 per Medicare recipient and also 
institutes a 50-percent discount on brand-name drugs.
  It gets health insurance to the uninsured. By creating a temporary 
insurance program, health care will be available for people who have 
been denied a policy due to preexisting conditions or who have not had 
health care for several months.
  It bans lifetime limits on health care coverage. The bill prohibits 
health insurance companies from placing lifetime caps on coverage--
traditional coverage or catastrophic care coverage.
  It provides health insurance for young people. It requires health 
insurance plans to allow young people through age 26 to remain on their 
parents' insurance policy at their parent's choice.
  It eliminates cost-sharing for preventive services in Medicare. It 
eliminates co-payments for preventive services and exempts preventive 
services from deductibles under the Medicare program.
  It ends health care rescissions. It prohibits insurers from 
nullifying or ``rescinding'' a patient's policy when they file a claim 
for benefits, except in cases of fraud.
  It bans copayments and deductibles. It eliminates copayments for 
preventive services and also exempts preventive services from 
deductibles under the Medicare program.
  It increases funding for community health centers. It increases 
funding for Community Health Centers to allow twice the number of 
patients seen by Community Health Centers for the next 5 years.
  It increases the number of primary care doctors. It increases the 
investment by the Federal Government in training programs to increase 
the number of primary care doctors, nurses, and public health 
professionals.
  Creates long-term health care for disabled adults. The bill creates a 
longterm care insurance program to be financed by voluntary payroll 
deductions to provide benefits to adults who become functionally 
disabled.
  As with Medicare and Medicaid, the Federal Government has the 
Constitutional power to reform our health care system. The 10th 
amendment to the U.S. Constitution states that the powers not delegated 
to the federal government by the Constitution, nor prohibited by it to 
the states, are reserved to the states . . . or to the people. Article 
One, Section Three, also known as the Commerce Clause, says the same 
thing. The Constitution gives Congress broad power to regulate 
activities that have an effect on interstate commerce. Congress has 
used this authority to regulate many aspects, from labor relations to 
education to health care to agricultural production. Since virtually 
every aspect of the heath care system has an effect on interstate 
commerce, the power of Congress to regulate health care is essentially 
unlimited.
  The Affordable Health Care for America Act is good for small 
businesses. Under this legislation, many small businesses will be 
eligible for a new tax credit to help them provide coverage for their 
workers and their families--and they or their workers will get access 
to a new comparison shopping marketplace with low rates and good 
benefits like large groups get. Without health insurance reform, small 
businesses would pay nearly $2.4 trillion over the next 10 years in 
health care costs for their workers. According to the nonpartisan Joint 
Committee on Taxation--only 1.2 percent of the wealthiest Americans 
will be subject to the surcharge and it would only apply to dollars 
earned over $1 million for a couple and $500,000 for an individual. 
Furthermore, 86 percent of all businesses are exempt from the 
requirement to provide health insurance coverage to their workers.
  Nothing in the House bill will cut basic Medicare benefits. The 
Affordable Health Care for America Act strengthens and improves 
Medicare benefits for older Americans and helps eliminate waste, fraud 
and inefficiency from Medicare--including gross overpayments to 
insurance companies providing Medicare Advantage plans which do nothing 
to improve care for Medicare Advantage beneficiaries.
  The Affordable Health Care for America Act is comprehensive health 
insurance reform that covers 96 percent of Americans, ensures 
affordability for the middle class, provides security for our seniors, 
ends discrimination by insurance companies against the sick, caps what 
Americans pay out-of-pocket and protects our children's future by not 
adding to our deficit.
  Finally, health care reform will allow the United States to catch up 
to the rest of the industrialized world. We are the only nation that 
does not provide universal health care coverage to its citizens. This 
puts the health of not only individual Americans at jeopardy, it puts 
the health of our economy in jeopardy. Businesses that have to compete 
with China, India, Europe and other countries are doing so on an 
uneven, unfair playing field, because while China, India and European 
businesses do not have to pay for health care, American businesses do. 
Health care reform will allow these businesses to truly compete on a 
global plane.
  I applaud my colleagues in the House of Representatives for 
supporting this legislation in ensuring that health care reform is 
accessible, available, and affordable for all Americans and American 
businesses. Two generations is long enough for the American people to 
wait for comprehensive health care reform. Health care is the key moral 
and economic imperative for our Nation and this Congress. We must 
reform health care now.
  Ms. CLARKE. Mr. Speaker, today, I rise in support of H.R. 3962, 
Affordable Healthcare for America Act. In the United States, one of the 
richest countries in the world, nearly 47 million Americans lack health 
insurance, 13.5 percent of which are New Yorkers. Last year alone, New 
York City's hospitals spent 1.2 billion dollars in charity costs. 
Tragically, people who are either uninsured or underinsured often have 
to go without vital healthcare simply because they cannot afford it.
  Every American has a human right to adequate physical and mental 
healthcare, and I believe that government has a responsibility to 
assist its citizens in securing quality healthcare. Unfortunately, my 
Republican colleagues don't seem to fully grasp the dire situation our 
healthcare system is in. Maybe they would have come up with a bill that 
actually addressed the deficiency in our broken healthcare.
  It is unfortunate that there are those who just don't care. Those who 
are satisfied with the status quo of rising premiums, satisfied with 
individuals being denied coverage because of preexisting conditions, 
satisfied with ignoring the pain and suffering of the 47 million 
Americans who are uninsured. Instead of working to fix the problem, 
they capitalize on people's fears and doubts. It is meant to distract, 
delay, confuse, and engender fear among our citizens. Today we will not 
allow the voices of fear to dominate the health care reform debate. 
This bill provides healthcare

[[Page 27495]]

coverage to 96 percent of Americans and includes a strong public option 
that will provide the needed competition to lower premium costs. That 
is why I support H.R. 3962, Affordable Health Care for America Act.
  In my district, the 11th Congressional District of Brooklyn, the 
Affordable Health Care for America Act will:
  First, improve employer-based coverage for 367,000 residents. As a 
result of the insurance reforms in the bill, there will be no co-pays 
or deductibles for preventive care; no more rate increases or coverage 
denials for pre-existing conditions, gender, or occupation; and 
guaranteed oral, vision, and hearing benefits for children.
  Second, it will provide credits to help pay for coverage for up to 
160,000 households, if they need to purchase their own coverage.
  Third, under the bill's insurance reforms, 11,900 individuals in the 
district who have pre-existing medical conditions will now be able to 
purchase affordable coverage.
  Finally, this bill will allow 11,300 small businesses to obtain 
affordable health care coverage and provide tax credits to help reduce 
health insurance costs for up to 11,400 small businesses.
  Healthcare is a fundamental human right, rather than a commodity. A 
year ago, Americans cast a historic vote to change the course of this 
Nation. Today, we cast this historic vote, to finally manifest the 
change they demanded. Access to Affordable Healthcare. I am proud to 
cast my vote in favor of this bill.
  Mr. Speaker, I believe that H.R. 3962, the Affordable Health Care for 
America Act, will improve health care for all of our constituents. 
Another significant benefit of this legislation, which has not received 
as much attention, will be the creation of new high paying jobs, high 
quality jobs in healthcare delivery, technology and research in the 
United States.
  First, this bill will create enormous demand for healthcare workers, 
especially in the area of primary care. Insuring that the millions of 
Americans, who currently have no insurance, will have access to primary 
care providers so that they can receive the preventive care they have 
been denied for too long. This influx of new patients will create a 
need for doctors, nurses and technicians, while reducing overall 
healthcare costs because of the new focus on preventative medicine. I 
support channeling resources, that for too long have been used to treat 
people once they become sick, into jobs and services that will prevent 
people from getting sick in the first place.
  Second, this bill will continue the efforts we began in the stimulus 
package to deploy new health information technologies that better 
manage both the quality of care and the cost of it. New health care 
exchanges and new demands on the health system to provide high quality 
and cost-effective health care will create new opportunities and 
markets for our brightest technological minds. They will be 
incentivized to develop high quality healthcare products at an 
affordable price.
  Third, this bill will create new research opportunities in this 
country. The Energy and Commerce Committee enacted a framework for 
allowing biosimilar competition in this country. This new class of 
medicines will help lower costs and bring competition to one area that 
is key to the future of our healthcare system. Biotechnology is on the 
cutting edge of efforts to reduce costly invasive procedures, thereby 
allowing our constituents to live healthier and more productive lives. 
The creation of this new class of medicines comes with requirements for 
new clinical research and testing. This research will create high 
quality, high paying jobs. It is imperative that we keep this research, 
and these jobs in this country. We cannot allow these research 
opportunities to leave this country, and I intend to work with the 
Secretary of HHS and the Commissioner of the FDA to ensure they stay in 
the United States.
  I do not look at this bill as a drain on our economy, like so many of 
its opponents on the other side of the aisle. I see this bill as an 
exciting opportunity to create the kind of jobs we so desperately need 
in this country, while at the same time improving the lives of all 
Americans. This bill will improve health care, create jobs and grow our 
economy.
  Mr. FATTAH. Mr. Speaker, in my fourteen years representing the people 
of Philadelphia and Montgomery County, Pennsylvania, I have had few 
opportunities as significant as this one to stand up for my 
constituents, their families, the future of our city and the destiny of 
our nation. This healthcare bill is the result of months of legislative 
negotiation and collaboration and answers the calls made for decades by 
mothers who could not alleviate the suffering of their children, 
conscience-minded small business owners who could not provide the 
healthcare coverage they knew their employees deserved and doctors and 
nurses who fought creatively to provide treatments they knew their 
patients needed and could never afford. I am proud that today we will 
take the most significant step in a century towards joining the rest of 
the industrialized world in assuring every American has access to the 
healthcare they need.
  It is the nature of democracy that this bill contains some provisions 
which I do not support. I believe women deserve access to the full 
range of legally assured health services on equal footing with men. I 
believe it is our responsibility to vigorously address the pernicious 
health disparities which disadvantage Americans of color and linguistic 
minorities. I believe overzealous efforts to deny some people 
healthcare on the basis of their immigration status will inadvertently 
limit care for native-born and legal residents as well. I believe a 
stow public option is the only way to ensure competition, choice and 
affordability in the American private insurance market. At the end of 
the day, we, as the Representatives of the people are called to speak 
for them. Rarely do we have the opportunity to so directly improve 
their standard of living. It is with the people of the Second District 
in mind, and the generations to come, that I enthusiastically vote yes 
for the Affordable Health Care for America Act.
  Ms. WOOLSEY. Mr. Speaker, at least 46 million Americans are uninsured 
right now. More than 85% of the uninsured are in working families. Even 
if you have health insurance now, without reform, the cost of health 
care for the average family of four is projected to increase by almost 
$2,000 a year. The need for health reform is urgent and that's why I 
rise in strong support of this historic bill.
  Many Members of Congress, myself included, continue to believe that 
the best way to provide high quality, affordable healthcare to everyone 
is to create a single payer health insurance system. However, while we 
would prefer single payer, we united behind a health reform bill with a 
robust public option.
  We believed, and still believe, that the robust public option, a 
public option based on medicare plus 5% rates is the best way to 
increase competition, bring down the costs of premiums, and provide 
everyone with a real choice between a private and public health 
insurance plan.
  In August, many thought the public option was dead. But the 
Progressive Caucus, Tri Caucus, and many in our leadership, made sure 
that the robust public option was very much a part of the debate in 
September and October.
  Because of the work of so many Members, we have a public option in 
the bill we are considering today. While it's not the plan I would have 
preferred, this public option will increase competition with private 
plans and provide a real choice in health insurance plans.
  In addition, there is language in the manager's amendment that will 
ensure that any increase in health insurance premiums must be 
justified, which will help make premiums more affordable for our 
Nation's working families.
  As we move into conference with the Senate, I look forward to 
continuing to work with my colleagues to ensure that we have the best 
possible bill. Therefore, Mr. Speaker, to increase competition and 
provide choice, any bill reported out of conference must retain a 
strong national public option that goes into effect when the health 
exchange begins, and, is not based on any triggers. I urge my 
colleagues to support this bill.
  Mr. HARE. Mr. Speaker, I wish to strongly voice my support for the 
Affordable Health Care for America Act on behalf of all hard working 
men and women across this great country and certainly in the State of 
Illinois.
  For decades, our government has debated the issue of extending 
healthcare to all, yet too many Americans still lack it and the 
security and peace of mind that comes with it. For those fortunate 
enough to be insured, rising costs are making it harder and harder to 
stay afloat. We, as members of this body, have the opportunity today to 
take a historic step toward passing the Affordable Health Care for 
America Act, so that quality health care can be more affordable and 
accessible to all Americans and their families. This bill will 
drastically reduce the number of uninsured, increase competition and 
lower costs through a public option, reform the insurance industry so 
Americans don't see their coverage unfairly denied or dropped, and put 
more money in our seniors' pockets by closing the Medicare Part D 
doughnut hole, all while reducing the deficit by $104 billion over 10 
years.
  With unemployment at its highest level since 1983, another 
significant benefit of this legislation that should be highlighted is 
the creation of new high-paying jobs in this country. Let me repeat 
that for some of my friends on the other side of the aisle, this bill 
will create high-paying, high-quality jobs in healthcare delivery, 
technology and research in the United States. This bill creates a 
framework for allowing biosimilar competition in this country, which 
has

[[Page 27496]]

the potential to lead to a new class of generic biologic medicines that 
will help lower costs and bring competition to one of the areas that 
will be key to the future of our healthcare system. The development of 
generic biologics or biosimiliars has the potential to create much 
needed jobs here at home in clinical research and testing. I intend to 
work with the Secretary of HHS and the Commissioner of the Food and 
Drug Administration to ensure that this new work is conducted here at 
home, in places like my home state of Illinois.
  This bill will additionally create enormous demand for healthcare 
workers, especially in the area of primary care. Insuring the millions 
of Americans in this country who currently have no coverage will allow 
them to see primary care providers and receive the wellness and 
preventive care they have been denied for too long. This influx of new 
patients will need doctors, nurses and technicians for their care, 
while reducing overall healthcare costs because they will receive care 
based around prevention as opposed to hospitalization. I support 
channeling resources, that for too long have been used to treat people 
once they become sick, into jobs and services that will prevent people 
from getting sick in the first place.
  The Affordable Health Care for America Act will continue the efforts 
this Congress first undertook in the Recovery Act that deployed new 
health information technologies throughout our healthcare system. These 
technologies help to better manage both the quality of care people 
receive and the cost at which they receive it. New health care 
exchanges and new demands on the health system to provide high-quality 
and cost-effective health care will create new opportunities and 
markets for our economy. Workers and industry together will be 
incentivized to create and develop products that will be a win/win for 
Americans: high quality health care at an affordable price.
  I was proud to work with my colleagues on the Education and Labor 
Committee to help shape this bill. I was pleased to have had the 
opportunity to add two critical pieces to this bill that are of great 
importance to my constituents: allowing for Small Employer Benefit 
Arrangements (SEBA), which facilitate the participation of small 
businesses and the self-employed in the Health Insurance Exchange; and 
protecting the ability of our nation's veterans to be able to enter 
into the Health Insurance Exchange to attain additional insurance for 
their dependents while retaining their VA health coverage. These 
provisions were common-sense improvements that make this great bill 
even better.
  I have cited many, but not all, of the reasons why I think this 
historic bill is worthy of my vote. I now ask that my colleagues join 
me in protecting American families from coast to coast in supporting 
this historic legislation. Mr. Speaker, thank you for your strong 
leadership on this issue and I look forward to proudly voting in favor 
of this bill in honor of the 39,000 uninsured residents of my District 
who would finally have the ability to receive the quality health care 
they deserve.
  Mr. PASCRELL. Mr. Speaker, I and others have spoken at length on the 
ways that the Affordable Health Care for America Act will improve 
health care for all of our constituents. Another significant benefit of 
this legislation which has not received as much attention will be the 
creation of new high-paying jobs in this country. Let me repeat that 
for some of my friends on the other side of the aisle: this bill will 
create high-paying, high-quality jobs in health care delivery, 
technology, and research in the United States.
  First, H.R. 3962 will create enormous demand for health care workers, 
especially in the area of primary care. Expanding meaningful health 
insurance coverage to the millions of Americans in this country who are 
currently uninsured or underinsured will allow them to see the primary 
care providers and receive the wellness and preventive care they have 
been denied for too long. This influx of new patients will need the 
doctors, nurses, and technicians necessary to deliver the care they 
need--while reducing overall health care costs as we prevent more 
expensive emergency care and hospitalizations. I support channeling 
resources that for too long have been used to treat people once they 
become sick into jobs and services that will prevent people from 
getting sick in the first place.
  Second, the Affordable Health Care for America Act will continue the 
efforts we began in the stimulus package to deploy new health 
information technologies that better manage both the quality of care 
people receive and the cost at which they receive it. New health care 
exchanges and new demands on the health system to provide high-quality 
and cost-effective care will create new opportunities and markets for 
our brightest minds in technology. They will be incentivized to create 
and develop products that will be a win-win for Americans--high quality 
health care at an affordable price.
  Third, H.R. 3962 will create high quality research opportunities for 
America. The legislation under consideration establishes a framework 
for allowing biosimilar competition in this country. This new class of 
medicines will help lower costs and bring competition to an area that 
is a key to the future of our health care system. Biotechnology is on 
the cutting edge of efforts to reduce costly invasive procedures and 
allow our constituents to live healthier and more productive lives. The 
creation of this new class of medicines comes with requirements for new 
clinical research and testing, especially in the area of new 
biosimilars' interchangeability with innovator products. This research 
will create high quality and high paying jobs, and it is imperative 
that we keep this research and these jobs in this country. The 
Inspector General of Health and Humans Services is currently 
investigating the amount of data received from overseas clinical 
trials. We cannot allow these research opportunities to leave this 
country, and I intend to work with the Secretary of HHS and the 
Commissioner of the Food and Drug Administration to ensure that the 
clinical studies to support the safety and interchangeability for this 
new class of follow-on biologics is conducted in the United States.
  Mr. Speaker, I do not view this legislation as a cost or drain on the 
economy of our country like so many of its opponents on the other side 
of the aisle. Instead, the Affordable Health Care for America Act is an 
exciting opportunity to create the kinds of jobs we so desperately need 
in this country while improving the lives of ALL Americans. H.R. 3962 
will improve health care, create jobs, and grow our economy.
  Mr. Speaker, I am pleased to support the Affordable Health Care for 
America Act. I could not be prouder that H.R 3962 expands coverage to 
96 percent of Americans in a fiscally responsible manner. I strongly 
believe that all interested parties should indeed have a stake in this 
necessary effort, but I would like to recognize the contribution asked 
of the biopharmaceutical industry.
  New Jersey has often been called the Medicine Chest for the World and 
for good reason. Last year, the biopharmaceutical and medical 
technology industries employed nearly 60,000 individuals in the state 
of New Jersey--with another 88,000 ``spin-off' jobs through the 
purchase of goods and services, capital construction projects, and 
other industry activity.
  H.R. 3962 extends Medicaid rebates to Medicare dual-eligible and low-
income subsidy beneficiaries while instituting a new 50 percent 
discount for Part D beneficiaries who find themselves in the 
prescription drug benefit coverage gap--the so-called ``donut hole.'' 
Pharmaceutical sales represent about 10 percent of national medical 
expenditures, but the savings generated from these provisions represent 
a disproportionately larger share of the legislation's savings and 
revenues.
  There is little doubt that these industries are sure to see increased 
sales both as millions of previously uninsured Americans and millions 
more who were underinsured are given access to meaningful health 
insurance that covers prescription medications and as seniors with 
expanded Part D coverage better adhere to the prescription regimens 
prescribed by their doctors. However, I have lingering concerns that a 
single industry may be paying more than their fair share and that this 
may have unfortunate consequences in New Jersey. The biopharmaceutical 
manufacturers in my state have estimated that as many as 12,300 jobs 
could be lost in New Jersey.
  I believe that H.R. 3962 is an effort that will indeed create new 
jobs in the health care sector both as the demand for health care 
providers increases and as the result of a new pathway for the 
development of follow-on biologics, and I applaud the legislation for 
taking steps to close the Medicare Part D donut hole. However, we must 
recognize there will be consequences for New Jersey's biopharmaceutical 
industry, and I express my hope that these consequences will be 
minimized as the House and Senate come together to formulate a 
compromise health reform package.
  Mr. Speaker, in my capacity as co-chair of the Congressional Brain 
Injury Task Force, I would like to share my understanding of the intent 
of the provisions of H.R. 3962--the Affordable Health Care for America 
Act--regarding the coverage of the treatment continuum for persons with 
brain injury.
  News reports of returning veterans and recent high profile brain 
injury stories indicate what researchers have been reporting for years: 
brain injury is a leading public health problem in U.S. military and 
civilian populations. I believe that any health care reform initiative 
must recognize that brain injury is not an event or an outcome but is 
the beginning of a lifelong disease process that impacts

[[Page 27497]]

brain and body functions. These impacts of brain injury can result in 
difficulties in physical, communication, cognitive, emotional, and 
psychological performance, undermining health, function, community 
integration, and productive living. Brain injury is also disease 
causative and disease accelerative because it predisposes individuals 
to re-injury and the onset of other conditions.
  The Brain Injury Association of America (BIAA) has developed a series 
of guiding principles for assessing any health care reform bill from a 
brain injury perspective. I believe, consistent with policy statements 
by the BIAA, that health care reform must address the unique health 
care needs of individuals with brain injury by recognizing that brain 
injury is the start of a lifelong disease process. As such, individuals 
with brain injury require access to a full continuum of medically 
necessary treatment--including rehabilitation furnished by accredited 
programs in the most appropriate treatment setting as determined in 
accordance with the choices and aspirations of the patient and family 
in concert with an interdisciplinary team of qualified and specialized 
clinicians.
  I am pleased to conclude that the Affordable Health Care for America 
Act reflects and is consistent with these principles.
  Principle 1: An individual with a brain injury should have an 
individualized medical treatment plan that documents specific 
diagnosis-related goals for individuals with a reasonable expectation 
of achieving measurable functional improvements through the provision 
of sufficient treatment.
  Under the bill, payment for items and services included in the 
essential benefits package should be made in accordance with generally 
accepted standards of medical and other appropriate clinical or 
professional practice. In addition under the bill, a qualified health 
benefits plan may not impose any restriction (other than cost-sharing) 
unrelated to clinical appropriateness on the coverage of the health 
items and services included in the essential benefits package. 
Consistent with medical, clinical, and professional practice, 
appropriateness should be determined based on the unique needs of the 
individual with brain injury and treatment should be of sufficient 
scope, duration, and intensity.
  Principle 2: An individual with brain injury should have access to 
the full treatment continuum to manage the disease. This continuum 
includes (1) early, acute treatment to stabilize the condition and (2) 
acute and specialized post-acute brain injury treatment and 
rehabilitation to minimize and/or prevent medical complication, recover 
function and cope with remaining physical or mental disabilities, and 
achieve long-term outcomes that maintain an optimal level of health, 
function, and independence following brain injury. These post-acute 
services include inpatient, outpatient, day treatment, and home health 
programs. I believe that for individuals with disabilities such as 
brain injury, rehabilitation and habilitation is equivalent to the 
provision of antibiotics to a person with an infection--both are 
essential medical interventions.
  I am pleased to report that under the bill, the essential benefit 
package includes, among other things, hospitalization, outpatient 
hospital and outpatient clinic services, professional services of 
physicians and other health professionals, prescription drugs, mental 
health and substance use disorder services (including behavioral health 
treatments), rehabilitative and habilitative services, and durable 
medical equipment, prosthetics, orthotics, and relates supplies. The 
term ``rehabilitative and habilitative services'' includes items and 
services used to restore functional capacity, minimize limitations on 
physical and cognitive functions, and maintain or prevent deterioration 
of functioning as a result of an illness, injury, disorder, or other 
health condition. Such services also include training of individuals 
with mental and physical disabilities to enhance functional 
development.
  Principle 3: Individuals with brain injury should receive treatment 
in the most appropriate treatment setting by accredited programs--
including acute care hospitals, inpatient rehabilitation facilities, 
residential rehabilitation facilities, day treatment programs, 
outpatient clinics and home health agencies. The treatment and 
treatment setting should be determined in accordance with the choice 
and aspirations of the patient and family in concert with an 
interdisciplinary team of qualified and specialized clinicians.
  I am pleased to report that under the bill payment for items and 
services included in the essential benefits package should be made in 
accordance with generally accepted standards of medical or other 
appropriate clinical or professional practice. The bill also requires 
adequacy of provider networks in order to ensure enrollee access to 
covered benefits, treatments, and services under a qualified health 
benefits plan. Rehabilitative and habilitative services should be 
available from a full continuum of accredited programs and treatment 
settings at a level of intensity that is consistent with the needs of 
the patient.
  Principle 4: The bill should prevent private insurance systems from 
delaying or denying treatment as a means of transferring the burden of 
brain injury care to taxpayers at federal, state and local levels; 
ensure that both public and private health insurance systems meet the 
health care needs of people with brain injury; and avoid using Medicaid 
and Medicare as the first option for the coverage of people with brain 
injury.
  I am pleased to report that the bill includes numerous requirements 
reforming the health insurance marketplace that should prevent private 
insurance systems from delaying or denying treatment for individuals 
with brain injury. These reforms include (1) prohibiting pre-existing 
condition exclusions, (2) requiring guaranteed issue and renewal, (3) 
requiring nondiscrimination in health benefits or benefit structure, 
(4) requiring adequacy of provider networks, (5) limiting cost-sharing, 
and (6) prohibiting the imposition of annual or lifetime limits on 
coverage. I believe that these provisions will help prevent private 
insurance from delaying or denying treatment to persons with brain 
injury.
  Finally, the bill includes provisions regarding modernized payment 
initiatives and delivery system reform under which the Secretary may 
use innovative payment mechanisms and policies to determine payment for 
items and services under the public health insurance option, including 
bundling of services. Separate provisions are included in the bill 
regarding post-acute care bundling under Medicare. BIAA, in a recent 
submission to the chairs of the Education & Labor, Ways & Means, and 
Energy & Commerce Committees, commented that post-acute payment systems 
must facilitate, not impede, improvements in functional status of 
individuals with brain injury and their ability to return to their 
homes and communities. BIAA supports a deliberative planning process 
and rigorous pilot testing. According to BIAA's comments, the 
deliberative process should determine whether post-acute care bundling 
should exempt diagnoses such as brain injury, that are of low 
predictability and highly complicated; establish certain minimum 
requirements for any bundling proposal such as ``any willing provider'' 
in the bundled payment system; and test innovative payment methods that 
make payments directly to non-hospital-based treatment centers, 
including residential rehabilitation facilities specializing in the 
treatment of brain injury.
  I believe that the deliberative process should address each of these 
issues. I also believe that the adoption of alternative innovative 
payment mechanisms and policies must be guided by the goals included in 
the bill--improving health outcomes, reducing health disparities, 
providing efficient and affordable care, addressing geographic 
variation in the provision of health services, preventing or managing 
chronic illness, and promoting care that is integrated, patient-
centered, quality, and efficient.
  I remain wary of mechanisms that bundle post-acute care to acute care 
hospitals for patients with complex and highly unpredictable diagnosis 
and health outcomes, like brain injury and other catastrophic 
conditions. Such payment systems should not impede, rather than 
facilitate, improvements in functional status and should not result in 
premature return to homes and undue levels of preventable disability 
without adequate facilitation of progression through necessary step 
down levels of treatment.
  Mr. LUETKEMEYER. Mr. Speaker, I have criticized many of the 
provisions of this bill and rightfully so.
  However, one bi-partisan area that strikes the appropriate balance in 
providing lower-cost options to consumers without destroying a healthy 
and functioning industry in this country that is included in both the 
underlying bill, which I strongly oppose, and the Republican 
substitute, which I intend to support, are the sections relating to the 
creation of a market for biosimilar products. These provisions were one 
of the few areas in the bill adopted on an overwhelming bipartisan vote 
for the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce 
Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and, at the same time, providing a safe and effective way 
to bring competition to benefit patients is a laudable achievement. I 
wish we could remove this provision from this fatally flawed piece of 
legislation and consider it separately because it would pass with the 
kind of overwhelming bi-partisan support that Americans across the 
country wish to see.

[[Page 27498]]

  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur, and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country. 
Unfortunately, many of the largest companies that would seek to enter 
the biosimilar market have made their money by outsourcing their 
research to foreign countries like India. With this week's devastating 
news that unemployment has reached 10.2%, it is critical that we 
preserve jobs in the United States. While the innovators have created 
jobs here, these generic companies have shipped them overseas, so they 
can turn around and sell cheap knockoffs of innovative American 
products.
  As this new market launches in the U.S., we need to ensure that we 
foster innovative products in this country for the creation of jobs and 
research that will go into proving whether these products are 
interchangeable with the innovators products. I have my doubts that 
these companies can create such interchangeable products, but I am 
certain that the research and testing of whether or not they can should 
occur in this country and not somewhere across the globe. Testing and 
research on these interchangeable biosimilars should be occurring in 
this country to ensure that it is done properly and safely and to 
benefit our economy.
  Mr. EDWARDS of Texas. Mr. Speaker, after listening to thousands of my 
constituents and carefully reviewing the legislation, I have made a 
decision to vote ``no'' on the House health care reform bill.
  Given the huge federal deficits facing our nation, I believe there is 
too much new spending in this bill.
  I am especially disappointed that the bill does not have a fiscal 
trigger in it to cut spending if actual costs of new programs turn out 
to be higher than projected.
  While the Congressional Budget Office predicts this bill is paid for 
over 10 years, there is no mechanism in the bill to force spending cuts 
if those complicated projections turn out to be wrong.
  I also have concerns about a government-run ``public option'' 
insurance company and question whether this bill goes far enough in 
actually reducing health care costs for working families and 
businesses.
  Throughout this debate I have heard two extremes. Some on the far 
left would like to see the federal government run a socialized health 
care system. Some on the far right would get the government completely 
out of health care, which would mean the elimination of Medicare and 
Medicaid. I think both extremes are wrong.
  I believe most people in our district recognize that health care 
reform is needed to hold down costs and to make health care more 
affordable and dependable, but they want any reform bill to be fiscally 
responsible. I agree.
  Mr. SHUSTER. Mr. Speaker, after weeks of closed-door meetings, 
Speaker Nancy Pelosi has brought her healthcare reform to the floor for 
a vote today on Saturday while the attention of the majority of 
Americans is diverted. The Pelosi plan clocks in at over 1,900 pages, 
which is 648 pages longer than Hillary-care and it costs over a 
trillion dollars, or about $2 million per word.
  The sheer size and scope of the Pelosi plan is enormous. As we enter 
a time of 10.2 percent unemployment, the American people will not 
accept a government takeover of healthcare that will kill even more 
jobs, hurt small businesses, increase the deficit now and drown future 
generations in stifling debt.
  While the sheer size and scope of the Democrats' takeover of 
healthcare prevents me from pointing out every egregious part of the 
proposal, I would like to point out four areas that should give all 
Americans pause.
  Taxes: The Pelosi plan would impose $730 billion in new taxes on 
businesses that can't afford to pay for their employees' health 
coverage. According to President Obama's own economic advisor, 
Christina Romer, these new taxes would put 5.5 million workers at 
serious risk of losing their jobs. Close to 32,500 small businesses in 
Pennsylvania would be at risk from this new healthcare surcharge.
  Deficit Spending: The Pelosi plan contains $1.055 trillion in new 
federal spending over the next ten years. All of this spending will be 
used to take healthcare decisions out of the doctor's office and 
centralize them in Washington, DC, requiring the creation of over 100 
new federal panels, commissions and unelected civil servants who will 
be charged with making decisions on your care.
  Senior's Coverage: Earlier this year, President Obama pledged that 
``the government is not going to make you change plans under health 
reform.'' Today, he and Nancy Pelosi are proposing $170 billion in cuts 
to Medicare Advantage. These cuts would force close to 38,000 enrollees 
in the 9th district out of Medicare Advantage and into regular 
Medicare.
  Personal Freedom: The Pelosi plan will bring the nationalization of 
one-sixth of our economy and the elimination of choice for a majority 
of Americans to extend coverage to a few.
  Republicans have an alternative focused on simple principles that 
will lower the cost of quality healthcare for all Americans. Our plan 
would let families and businesses buy health insurance across state 
lines and pool together and buy health insurance at lower prices. We 
would give states the tools to create their own innovative reforms that 
lower health care costs. Finally our plan would end excessive and 
unnecessary tests doctors perform that contribute to higher health care 
costs to protect against junk lawsuits.
  Real health care reform should foster a system where competition and 
patient choice drive quality care and success. I believe we can 
accomplish this and fix what is broken in our health care system 
without forcing another trillion-dollar government takeover on 
taxpayers. I urge all of the members of this House to vote no on this 
reckless reform package. Vote no on a government takeover of 
healthcare.
  Mr. PUTNAM. Mr. Speaker, America is at a crossroads and we, as 
Members of Congress have the duty and responsibility to ensure our 
great country remains vibrant and competitive in the 21st Century. For 
that reason, I cannot figure out why the Democratic leadership and the 
administration want to rush to pass this monstrosity of a bill, with 
its $1 trillion price tag and $730 billion in taxes. I can confidently 
say that passing this health care reform bill will unwind private 
health care in America and at the same time do very little to bring 
down its cost.
  I rise today to speak in strong opposition to the legislation before 
us, H.R. 3962. This measure is indeed historic--an historic expansion 
of the role of government in the lives of every American. Your choice 
of physician . . . your choice of medical facility . . . your choice of 
the kind of care and treatment you receive . . . these are some of the 
most personal decisions you can ever make. The prospect of placing 
those decisions into the hands of a new federal bureaucracy that would 
combine the efficiencies of FEMA with the compassion of the Department 
of Motor Vehicles ought to alarm every American.
  So we are gathered here, to vote on legislation that is nearly twice 
the length of the original bill, H.R. 3200, that was introduced this 
summer. Mr. Speaker, I doubt that there are many people in this great 
hall who can honestly tell you they are fully conversant with every 
provision in this bill. But after doing our best to read, study and 
understand the nearly two-thousand pages of H.R. 3962 we know certain 
things this bill will do. For example, we know it will cost taxpayers 
more than a trillion dollars. We know it will impose $730 billion in 
new taxes on small businesses and individuals. We know it will cost 
five-and-a-half million Americans their jobs. We know it will create 
over 100 new bureaus, commissions, and programs. And we know it will 
burden our states with tens of billions of dollars in new unfunded 
federal mandates. In Florida alone, the additional costs associated 
with the Medicaid mandates will be in the billions of dollars.
  Mr. Speaker, we are told by the President and by the majority party 
in Congress that we need all this in order to make health care more 
affordable for the American people. How are we making health care more 
affordable if we are driving the American people into bankruptcy by 
taking historic steps toward a federal takeover of the entire health 
care system?
  The Democrat Majority seeks to pay for their health care reform bill 
in part through 8 percent payroll penalty taxes on employers who cannot 
afford to provide insurance coverage, and through a 5.4 percent surtax 
on individuals making $500,000 a year or more. These provisions are 
estimated to bring in more than $595 billion.
  You don't have to be an economist to know that these new taxes will 
have a direct and adverse affect on small businesses across America. An 
overwhelming majority of small businesses--approximately 75 percent of 
them--pay their business taxes through the owner at the individual 
level. Essentially, one in every three small businesses would be 
subject to the new surtax and just in the State of Florida as many as 
57,000 small businesses would be affected. These provisions are 
effectively a tax on jobs that will stifle job creation and depress 
wages. In light of the latest unemployment numbers of 10.2 percent for 
the U.S. and 11 percent for Florida, this is hardly the time to raise 
costs on small businesses and employers.

[[Page 27499]]

  If the taxes on America's small businesses were not enough, this bill 
also imposes a 2.5 percent tax on medical devices. At a time when our 
country spends about 17 percent of its GDP on health care, and we are 
tasked with developing policies to bring down the overall cost of care, 
it is irrational that we should tax an industry that is such an 
integral part of health care. This tax, on everything from syringes to 
artificial hips, will undoubtedly be passed along to the consumer.
  Mr. Speaker, America has the best health care system in the world. 
Why should we destroy the economic backbone of America to create a 
government-run health care plan that the majority of Americans oppose? 
It does not have to be this way.
  We can take significant steps to address health care--steps guided by 
principles based on the freedom of choice, transparency and openness, 
and a competitive free market.
  We can lower health care premiums for American families and small 
businesses, addressing Americans' number-one priority for health care 
reform.
  We can establish a universal access program to guarantee access to 
affordable health care for people with pre-existing conditions. The 
Republican alternative plan creates Universal Access Programs that 
expand and reform high-risk pools and reinsurance programs to guarantee 
that all Americans, regardless of pre-existing conditions or past 
illnesses, have access to affordable care.
  We can curb the cost of defensive medicine in this country by putting 
an end to ``junk lawsuits.'' The fear of lawsuits drives doctors to 
order expensive tests and procedures for patients, and not necessarily 
because they think they are in the best interest of the patients. Some 
doctors have even had to close their doors because they cannot afford 
the malpractice insurance premiums. It is evident that meaningful 
medical malpractice reform should be a component of any health care 
reform proposal. The Republican plan would help save $54 billion in the 
health care sector by including measures that have been successfully 
demonstrated in California and Texas.
  Just as we all want to reduce the cost of care, we should seek 
innovative ways to provide coverage without breaking the bank. We can 
do this by empowering small businesses with the opportunity to pool 
together and negotiate lower health care premiums--just as corporations 
and labor unions do--through association health plans. Another common 
sense reform would allow Americans to shop for coverage from coast to 
coast across state lines.
  We can promote prevention and wellness by giving employers greater 
flexibility to financially reward employees who adopt healthier 
lifestyles. Incidentally, about 75 percent of medical spending goes 
toward the treatment of chronic diseases. Research shows that the 
number of individuals suffering from chronic diseases like diabetes and 
heart disease could be reduced through proper wellness, prevention, and 
disease management programs. The Republican alternative would allow for 
employers to offer flexible coverage options to reward and encourage 
healthy behaviors in an effort to reduce overall spending on costly 
chronic diseases.
  We can do all of these things and more, Mr. Speaker. And we can do 
these things with legislation that the Congressional Budget Office says 
will lower premiums by up to 10 percent and reduce the deficit by $68 
billion over the next ten years, without imposing tax increases on 
families and small businesses.
  This alternative will give Americans access to health care, it will 
free up our medical system to become more innovative and efficient, and 
it is what Americans expect from their country.
  Mr. Speaker, this alternative is what this Congress should be sending 
to the President's desk--not the mammoth, unwise, and extraordinary 
expansion of government embodied in H.R. 3962.
  I urge my colleagues to vote ``no'' on this bill.
  Ms. JENKINS. Mr. Speaker, I have criticized many of the provisions of 
this bill and rightfully so. However, I do believe the sections 
relating to the creation of a market for biosimilar products is one 
area of the bill that strikes the appropriate balance in providing 
lower cost options to consumers without destroying a healthy and 
functioning industry in this country. These provisions were one of the 
few areas in the bill adopted on an overwhelming bipartisan vote for 
the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce 
Committee.
  Creating a pathway for new products that doesn't destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technologies and at the same time providing a safe and effective way to 
bring competition to benefit patients is a laudable achievement. I wish 
we could remove this provision from this fatally flawed piece of 
legislation and consider it separately because it would pass with the 
kind of overwhelming bipartisan support that Americans across the 
country wish to see.
  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country. 
Unfortunately, many of the largest companies that would seek to enter 
the biosimilar market have made their money by outsourcing their 
research to foreign countries like India. While the innovator's have 
created jobs here, these generic companies have shipped them overseas, 
so they can turn around and sell cheap knockoffs of innovative American 
products.
  As this new market launches in the U.S., we need to ensure that we 
foster innovative products in this country for the creation of jobs and 
research that will go into proving whether these products are 
interchangeable with the innovators' products. I have my doubts that 
these companies can create such interchangeable products, but I am 
certain that the research and testing of whether or not they can should 
occur in this country and not somewhere across the globe. Testing and 
research on these interchangeable biosimilars should be occurring in 
this country to ensure that it is done properly and safely and to 
benefit our economy.
  Mr. CONAWAY. Mr. Speaker, I have criticized many of the provisions of 
H.R. 3962, the Affordable Health Care for America Act, and with good 
reason. However, I believe that the creation of a market for biosimilar 
products is one area of the bill that strikes the appropriate balance 
in providing lower cost options to consumers without destroying a 
healthy and functioning industry in this country. These provisions were 
adopted on an overwhelming bipartisan vote for the Eshoo-Inslee-Barton 
(EIB) amendment in the Energy and Commerce Committee.
  Creating a pathway for new products that does not destroy the ability 
or the incentives for innovator companies to develop breakthrough 
technology and at the same time provide a safe and effective way to 
bring competition to benefit patients is a creditable achievement. 
Ideally, this provision would be removed from this fatally flawed piece 
of legislation and considered separately, as it would pass with 
overwhelming bipartisan support.
  These provisions are the first step on the long path to the marketing 
of these new products. New research and clinical testing will have to 
occur, and the FDA must write rules that will ensure that research is 
done safely and effectively. I have long supported the U.S. 
biotechnology industry as it has been a strong engine of job creation 
in this country. Unfortunately, many larger companies that seek to 
enter the biosimilar market have outsourced research to foreign 
countries. With this week's devastating news that unemployment has 
reached 10.2 percent, it is critical that we preserve jobs in the 
United States.
  As this new market launches in the United States, we must foster 
innovative products at home to create jobs, and conduct research that 
will prove whether products are interchangeable with innovators' 
products. It is unlikely that these companies can create such 
interchangeable products; however research and testing will prove if it 
can be conducted within our borders without being outsourced.
  Mr. HONDA. Mr. Speaker, in our lives as public servants, Members of 
Congress are rarely presented with opportunities to support the passage 
of truly historic legislation. Today is such a day, and this health 
care vote such an opportunity. Over the past ten months that I have 
participated in the creation of this health reform bill, I have been 
thinking about the words of Hubert Humphrey: ``It was once said that 
the moral test of government is how that government treats those who 
are in the dawn of life, the children; those who are in the twilight of 
life, the elderly; and those who are in the shadows of life, the sick, 
the needy and the handicapped.''
  Today I rise in strong support of H.R. 3962, the Affordable Health 
Care for America Act. For 70 years Americans have been waiting for this 
moment. I would like to particularly thank Speaker Pelosi for her deft 
leadership and management of a complex policy debate, Majority Leader 
Hoyer, Majority Whip Clyburn, the Chairs of the Committees on Energy 
and Commerce, Education and Labor, and Ways and Means, along with my 
fellow progressive and colleagues in the Congressional Asian Pacific 
American Caucus, Congressional Black Caucus, and Congressional Hispanic 
Caucus (collectively known as the TriCaucus) for their public and 
private commitments to preserve the public option. Finally, I commend 
staff of

[[Page 27500]]

all the committees for their hard work and commitment to this issue.
  Against an organized, scorched earth campaign of misinformation and 
fear mongering, we are emerging with a strong bill, and an even 
stronger sense of unity and purpose in our fight to bring access, 
affordability, and high quality health care to every person in America. 
If the best of our reforms prevail, insurance companies will no longer 
be able to subject people to complex, confusing policy details, 
lifetime and annual limits, or denials based on pre-existing 
conditions. American taxpayers will save over $100 billion in the first 
decade and will experience significant improvements in our health care 
system.
  Although I have strenuously supported a stronger public option, I 
recognize that the balance of improvements made to the health care 
system as a whole through the reforms in this bill is substantial. When 
some thought the public option was dead, I and my other colleagues 
rallied to bring it back into the discussion and succeeded in keeping 
the public option in the final bill. The public option is a cornerstone 
of the effort to bend the cost curve in health care and must be 
preserved.
  In my district alone, H.R. 2692 will improve employer based coverage 
for 500,000 residents, allow 16,700 small businesses to obtain 
affordable health care coverage and provide coverage for 28,000 
uninsured residents. Finally, in a time of increasing pressure on local 
governments, it will reduce the cost of uncompensated care for 
hospitals and health care providers by $205 million. It will protect 
the seniors in my district from the doughnut hole and improve the 
quality of their Medicare coverage.
  As Chairman of the Congressional Asian Pacific American Caucus, I am 
particularly encouraged by the inclusion of legislative language 
addressing racial and ethnic health disparities. As members of the 
TriCaucus, we have long been advocating on the issue of health 
disparities and I am proud of the impact we have had in making changes 
that will directly help the poorest and most disadvantaged communities. 
across this nation. As a long-time supporter of Native Americans in 
their struggle to survive and thrive after hundreds of years of 
oppression and genocide, I am particularly pleased by the inclusion of 
the Indian Comprehensive Health Insurance Act in health care reform. 
Native American communities worked for over a decade to come together 
and write policy that would help their communities begin to address the 
terrible and tragic health disparities they experience and the 
inclusion of ICHIA is a step in the right direction by the Federal 
Government to rectify some of the imbalances and abuses that they have 
caused in Native communities.
  Despite the many extraordinary improvements to many aspects of our 
healthcare system, including an unprecedented expansion of access to 
Medicaid for many poor families, I am dismayed that we were not able to 
lift the 5 year bar on legal immigrant participation in Medicaid. Legal 
immigrants are tax paying citizens in waiting who work hard and 
contribute. It is only fair that we afford them equal access to the 
benefits of Medicaid. I will continue to advocate on this issue in the 
future and I know that I am joined in my concern by many of my 
colleagues.
  Americans live in the wealthiest, most powerful nation in the world 
and spend $2 trillion a year on health care every year--more than the 
national budget of China--and yet we don't have the best health care in 
the world. Thousands suffer and many die because of a lack of access to 
health care. Passing this bill and preserving its structure is a 
critical investment in the health of future generations.
  Mr. CALVERT. Mr. Speaker, I rise today in objection to the Pelosi 
Health Care Bill which creates over $1 trillion in new government 
spending. It is funded with the ``Hope'' that our children will figure 
out how to pay the bill tomorrow and with a ``Change'' in the Medicare 
program that cuts $500 billion from the over 45 million beneficiaries 
currently covered.
  Provisions within the Pelosi Health Reform Bill will raise premiums 
and lower access to care for America's seniors. Although Democrats try 
to present these changes to Medicare as improvements and savings, the 
White House's own actuaries have stated that these changes will 
increase Medicare spending at a greater rate than if we had done 
nothing at all. With the Centers for Medicare and Medicaid Services 
reporting earlier this year that the Medicare trust fund will be 
exhausted by 2017, I do not believe this Congress should take any 
action that hastens the jeopardy already faced by America's seniors.
  The Pelosi Health Care Bill cuts $170 billion from the Medicare 
Advantage Program, which covers almost 50 percent of the Medicare 
beneficiaries in the 44th Congressional District of California--36,124 
senior citizens who rely on this highly successful program for their 
health care needs. The cuts undermine a program that currently gives 
seniors the choice to enroll in a private option and that provides the 
same benefits as traditional Medicare, prescription drug and other 
additional health benefits, usually with lower copayments.
  The proposed changes also will result in reduced benefits for 
Medicare Advantage beneficiaries or result in higher premiums and 
copayments for fixed income seniors. But let me be clear--not for an 
improvement in service, but for the same or reduced level of service. 
For the workforce paying into the Medicare program, higher taxes are 
ahead.
  In addition to the increased tax burden working Americans will face 
to keep Medicare afloat, this bill levies a 2.5 percent tax on the 
incomes of hardworking working Americans who cannot afford insurance. 
This breaks a fundamental promise of President Obama's campaign that he 
would not raise taxes on the middle class.
  And even as the national unemployment climbs above 10 percent 
nationwide--over 20 percent in some parts of my district--Speaker 
Pelosi seeks to place an 8 percent tax on small businesses who cannot 
afford to provide government mandated ``acceptable insurance'' to their 
employees. In this economic climate, Congress should be working to 
enact real reform across the United States that creates jobs and 
stimulates the economy, not enacting a government expansion and tax 
regime that will put the jobs of at least 5.5 million largely low wage 
earners, minorities and young people at risk.
  Finally, while Americans struggle to pay their bills and put food on 
the table, Speaker Pelosi wants even more of their tax dollars to be 
spent to provide federal health benefits to the 12 million illegal 
immigrants currently in the United States. As I understand the bill 
before us today, a person would only need to ``declare'' that they are 
a citizen, provide a name and Social Security number and they would be 
eligible to receive health insurance benefits. There is no requirement 
for the verification of identification documentation. It is absolutely 
unacceptable that this bill would not, at a minimum, require even one 
verified identification document in order to receive taxpayer funded 
health care benefits. The bill should include clear processes and 
require documentation to confirm that an individual applying for health 
care benefits is a citizen or legal resident of the United States like 
the E-Verify program I created in 1996 for employers to verify the 
legal status of new employees.
  The crafting of the bill before us today spent American liberties to 
purchase House Democrat votes in order to secure a political victory. 
The resulting legislation has put freedom and American ingenuity under 
the knife. For the sake of American jobs, American families and future 
generations, we must kill this bill and resume our work to create jobs, 
rein in government spending, increase healthcare freedom and choice and 
getting the U.S. government's financial house back in order.
  However, I look forward to voting in favor of the Stupak-Pitts 
Amendment, which maintains the current federal government policy of 
preventing federal funding for abortion and for benefits packages that 
include abortion. This amendment ensures that federal taxpayers will 
not be coerced into funding elective abortions and is supported by U.S. 
Conference of Catholic Bishops, Democrats for Life, National Right to 
Life, Americans United for Life, Family Research Council, Concerned 
Women for America and many other pro-life groups. I look forward to 
continuing to work to ensure taxpayer funds are not used to fund 
abortions and to provide the broadest possible conscience protections 
for physicians, health professionals, hospitals, insurers, and all 
those in the business of caring for the health of Americans.
  Mr. DICKS. Mr. Speaker, we have reached a pivotal moment in the House 
of Representatives today as we are about to approve the most 
significant expansion of access to health care in America in at least a 
generation. And the bill we are about to approve also represents the 
most substantial improvement of the quality of health care in our 
country that has been passed in the entire time I have been in 
Congress. I am proud to support this long-overdue and aptly-named 
legislation, the Affordable Health Care for America Act.
  I am particularly pleased that we have come to an agreement within 
this bill on a provision that I believe will lead to a dramatic 
improvement in the way we pay for health care for America's seniors 
under Medicare. Under the current Medicare payment system, providers 
are reimbursed on a ``fee-for-service'' system that encourages more 
procedures and office visits. One of the most encouraging aspects of 
H.R. 3962 is language that will help shift Medicare to a system that is 
more efficient and that encourages better coordination of health care 
for seniors.

[[Page 27501]]

  Medicare's complex reimbursement formula has long punished doctors 
for providing more cost effective, quality health care. It is truly 
unfair under our current system that Medicare spends $7,363 per 
enrollee in a city in my district--Tacoma, Washington--while it spends 
twice that amount, $14,946, in the small Texas town of McAllen. These 
differences are largely due to discretionary decisions by physicians 
that are influenced by the local availability of hospital beds, imaging 
centers and other resources--and a payment system that rewards growth 
and more intense use of medical facilities and testing. But this focus 
on utilization is not only inherently more costly, it tends to ignore 
the health care outcomes, which should really be the goal of any system 
of care. And it exacerbates the problem we are already facing with 
Medicare: out-of-control growth rates. At current trajectory, Medicare 
will be $660 billion in the red by 2023, highlighting the urgent need 
to find ways to trim this growth rate. If we could reduce the annual 
growth in per capita Medicare spending from the national average--3.5 
percent--to 2.4 percent, the rate in San Francisco, Medicare could save 
$1.42 trillion over that period and turn the deficit into a healthy 
surplus.
  So in order to help move us toward this goal and produce a more 
equitable system of reimbursement, I was pleased to work with a number 
of concerned Members here in Congress on language in this bill that 
will enlist the resources of the independent, non-profit Institute of 
Medicine to examine the existing Medicare geographic payment inequities 
for both physician and hospital payments and to address the inequities 
that are clearly contained in our current system. We are also investing 
$4 billion per year in 2012 and 2013 to make payment rate adjustments 
so that no geographic area will be disadvantaged during 2012 and 2013.
  I am also pleased that a related provision of this bill calls for an 
additional study by the Institute of Medicine to conceptualize a system 
of Medicare payments based on quality outcomes versus the current 
system of ``fee-for-service.'' This ``High-Value Study'' will be 
completed by April 15, 2011 and the Institute's recommendations will be 
submitted to the Secretary of Health and Human Services, who will then 
have 240 days to submit a final implementation plan to Congress. This 
plan will take effect unless Congress passes a resolution of 
disapproval by the end of May 2012.
  These are very important reforms that I believe will help ensure the 
solvency of Medicare and promote a more equitable system of health care 
for seniors that stresses results over process. They are among the many 
aspects of this overall health care reform package that deserve our 
support, and I am proud to be speaking today to recognize these 
provisions and to urge all my colleagues to pass the Affordable Health 
Care for America Act.
  Mr. WALZ. Mr. Speaker, over the past three years, I've discussed 
health care reform with thousands of my constituents. I've heard from 
doctors and nurses, health care policy experts and small business 
owners. Most importantly, I've heard from middle-class Minnesotans who 
are fed up with the status quo.
  Take Kristy, who is a Rochester mother and breast cancer survivor. 
Access to affordable health insurance is a life or death matter for her 
and millions of other Americans.
  Last year, Kristy's health insurance premium increased 17 percent. 
Hard-working Americans every year see premiums rise faster than their 
take-home pay. This is a financial disaster in progress. If ignored, 
this will result in an explosion in the number of uninsured 
individuals, reaching far into the ranks of the gainfully employed and 
middle class.
  Kristy's employer laid-off workers this year, in part because of 
rapidly rising health care costs. Small businesses across America are 
shedding good workers to cover sky-rocketing health care expenses, 
stifling entrepreneurship and innovation.
  And then, recently, Kristy lost her job. She worries about whether 
she'll be able to get health insurance given her pre-existing medical 
condition, once her temporary COBRA coverage expires.
  Last year, more than 700 of our neighbors in southern Minnesota went 
bankrupt because of medical bills. It is unconscionable for anyone to 
go broke solely because they get sick. Now, Kristy wonders if she's 
next.
  Kristy's story has become all too common in America today.
  It doesn't have to be this way.
  I rise today in strong support of H.R. 3962, the Affordable Health 
Care for America Act, because of people like Kristy. This bill, which 
includes important fixes from Democrats and Republicans, will tear down 
the status quo, rein in costs and bring stability and peace of mind to 
regular people like Kristy.
  The House health care bill has four important pillars of reform:
  The first pillar stops run-away costs and rewards quality care. A 
patient-centered initiative spearheaded by Mayo Clinic is at the heart 
of rewarding quality. The current fee-for-service payment model in 
Medicare perversely encourages health care providers to perform 
unnecessary procedures and tests. This is backwards. Hospitals and 
doctors should instead be rewarded for innovation, results, and quality 
care. The Mayo-backed solution in this bill asks experts at the 
independent Institute of Medicine to come up with and help implement 
new pay-for-results policy in Medicare. This will help deliver better 
care for our seniors.
  The second pillar reforms the insurance industry to benefit ordinary 
folks. It provides overdue transparency and accountability by ending 
health insurance companies' blanket exemption from anti-trust laws. 
Firms will no longer be shielded from liability for price-fixing or 
monopolizing. We've seen what happened on Wall Street when corporations 
got too big to fail and their books too confusing to understand.
  It goes further to protect consumers by making it illegal to deny 
coverage for pre-existing conditions like Kristy's or charging more 
based on gender, occupation, or health status. It also caps annual out-
of-pocket expenses and prohibits unfair limits on benefits to ensure no 
American goes bankrupt because of illness. And, it allows individuals 
up to the age of 27 to stay on their parents' insurance plan.
  The third pillar promotes competition and choice for people who don't 
have insurance today or lose it in the future. Under the bill, 
Americans will be required to obtain health insurance, just like 
drivers are mandated by state law to purchase auto insurance.
  People who don't have health insurance today or lose it in the future 
can participate in the Health Insurance Exchange where they can compare 
and purchase insurance products that best meets their needs. An 
analysis by MIT Economist Jonathan Gruber found that premiums for folks 
in the Exchange will be lower than they would be if those same people 
were buying individual insurance in today's market.
  Privately-owned insurance companies, member-owned cooperatives, and a 
government-backed public option will compete for business in the 
Exchange. Low-income workers will get financial credits to help them 
afford to buy insurance.
  Another solution brought up at my town hall meetings and championed 
by Minnesota's Republican Governor Tim Pawlenty is fostering 
competition and lower costs through interstate insurance sales. The 
House health care bill allows states to work together to do just that.
  Finally, the fourth pillar will improve seniors' access to quality, 
affordable health care and protect the doctor-patient relationship. It 
addresses one of seniors' top concerns by immediately beginning to fill 
in the Medicare Part D donut hole which will make prescription drugs 
more affordable.
  I joined the President and Republicans in demanding that health care 
reform be fiscally responsible. The bill before us now is paid for and 
does not add to the national debt, according to the nonpartisan 
Congressional Budget Office.
  To the defenders of the status quo who are opposing health insurance 
reform, I have one question for you: How does your plan help people 
like Kristy?
  I encourage my colleagues to stop playing political games and come 
together across party lines to solve the problem. Vote yes on H.R. 
3962, the Affordable Health Care for America Act.
  Mr. MANZULLO. Mr. Speaker, America's health care system is in need of 
reform. The families in the congressional district I represent have 
seen their health premiums consume more and more of their salary. 
Employers are faced with the difficult decision regarding whether or 
not they can continue to afford to offer their employees the health 
coverage they know they need. Many more wish they could offer their 
employees coverage but the orders just aren't there, not in this 
economy. Doctors and other health providers have seen their 
reimbursements decline while their practice costs have risen and their 
liability insurance premiums have skyrocketed due to those who abuse 
our lawsuit system. Some doctors have reached the conclusion that they 
can no longer accept Medicare or Medicaid patients.
  I have spent my entire tenure in Congress working to reform our 
health care system to help these families, employers, and health 
providers. I have worked to pass association health plans so that small 
businesses can join together with other small businesses from across 
the country to grow their purchasing power on behalf their employees. I 
have also supported allowing Americans to obtain health insurance 
through other larger purchasing pools such as their church 
denomination,

[[Page 27502]]

alumni association or other memberships. The Republican Congress twice 
passed association health plans only to come up short as a result of 
Democrat opposition in the Senate.
  I have worked to pass health care options that meet the unique needs 
of families, such as medical savings accounts, health savings accounts, 
and flexible spending arrangements. These important initiatives allow 
families to save for future health needs and have been an important 
tool for small businesses. However, I have also had to defend these 
successful plans from assault by those who seek sources of revenue to 
fund tried-and-failed big government programs.
  I have worked to pass medical liability reform to reduce the high 
premiums that are driving doctors and other health providers from 
practice. Doctors in the district I represent face medical liability 
premiums three to four times as high as their colleagues just north of 
the border in Wisconsin as a result of Wisconsin's sensible cap on the 
third-layer non-economic, punitive awards. The Republican Congress 
twice passed medical liability reform only to have the reform die in 
the Senate as a result of Democrat opposition.
  I have worked to revise the flawed payment formula for doctors who 
treat Medicare patients to ensure that our seniors continue to have 
timely access to the most talented medical professionals in our 
community. I have worked to make sure that none of our health providers 
are targeted unfairly by government policies or agencies.
  And I have spent over 75 percent of my time trying to improve the 
economic climate for the manufacturers and other small businesses back 
home so that they can not only remain competitive world-wide, but also 
be able to offer competitive health care benefits for their employees.
  Today, I support a Republican plan that continues to pursue these 
important reforms. Rather than punish small businesses with onerous 
mandates and tax penalties for not offering health coverage, the 
Republican plan will provide tools for small businesses to pool 
together, just as larger corporations or labor unions do, to offer 
health care to their employees at lower prices.
  The Republican plan would save $54 billion by helping to restore 
common sense to the legal system and curb defensive medicine by 
enacting medical liability reforms modeled after the successful state 
laws of California and Texas. This will dramatically reduce health 
costs for doctors and patients and will reduce the need for expensive 
additional tests or procedures that do nothing to improve health status 
but simply are ordered because of the threats of lawsuits.
  The Republican plan will lower health insurance premiums for all 
Americans. The non-partisan Congressional Budget Office estimated that 
premiums would be reduced by 10 percent for employees who receive their 
coverage through their small business employer; 8 percent for those who 
do not have access to employer-provided coverage; and 3 percent for 
employees who receive their coverage through a larger business. 
Families will see their premiums $5,000 lower than the cheapest 
government run health insurance plan offered by the Democrats.
  The Republican plan provides options for those with pre-existing 
conditions or those otherwise unable to afford health insurance through 
state high risk pool options designed to meet the unique regional needs 
of local citizens. The Republican plan provides options for young 
adults to remain on their parents' health plans.
  The Republican plan promotes innovation in the areas of coverage, 
technology, and wellness, and prevents government bureaucrats from 
coming between a doctor and patient. It preserves existing law 
preventing federal funding from paying for elective abortions. It 
doesn't raise taxes; it doesn't cut Medicare benefits; it doesn't force 
anyone into a new government-run health program; and rather than 
increasing the debt burden on our children and grandchildren, the CBO 
estimates that the Republican plan will save $68 billion over the next 
ten years.
  Unfortunately, the bill offered by House Speaker Nancy Pelosi (D-CA) 
takes a very different approach. The Pelosi bill is a $1.3 trillion 
dollar federal government takeover of the entire health care sector. It 
increases taxes by $766 billion, taken from badly needed capital for 
operations and loans for small businesses and is estimated to kill 5.5 
million jobs. It penalizes employers for not offering and employees for 
not purchasing the health coverage that a new all-powerful Health 
Choices Commissioner deems acceptable. It increases the cost of health 
care for patients and other health consumers through a new 2.5 percent 
tax on medical equipment, such as wheel chairs. The Pelosi plan cuts 
$500 billion from Medicare, which will hurt 18,425 seniors from the 
Congressional district I represent. District hospitals will see their 
Medicare payments cut by $244.7 million and local skilled nursing 
facilities will lose $113.4 million.
  Despite claiming the goal of decreasing health costs, the Democrat 
bill creates 111 new bureaucracies, commissions, agencies, or offices, 
necessitating the hiring of thousands of new bureaucrats. These new 
czars and commissars will micromanage all aspects of Americans' health, 
including the following from page 1514: ``The Secretary shall establish 
by regulation standards for determining and disclosing the nutrient 
content for standard menu items that come in different flavors, 
varieties, or combinations, but which are listed as a single menu item, 
such as soft drinks, ice cream, pizza, doughnuts, or children's 
combination meals, through means determined by the Secretary, including 
ranges, averages, or other methods.''
  This Pelosi bill irresponsibly shifts significant costs to the states 
by hiking their Medicaid expenses. Most states already face significant 
existing Medicaid shortfalls as demonstrated by the Medicaid bailout 
for states contained in the Democrat stimulus bill.
  The creation of a new government health insurance exchange through 
which all insurance must be approved and through which all individual 
insurance must be sold will jeopardize the insurance choices currently 
enjoyed by over 85 percent of Americans. The creation of a government 
run health insurance plan coupled with a heavy-fisted regulatory scheme 
tipped significantly in its favor will further erode the Americans 
choice of coverage and eventually result in most Americans being forced 
into a full-blown government run insurance scheme. Further troubling is 
the inclusion of comparative effectiveness research panels that are 
utilized in European single-payer systems to ration health care based 
on cost factors.
  And despite the CBO's estimate on the significant savings that could 
be achieved, the Democrat bill not only contains no medical liability 
reform, but it actually incentivizes states to repeal their existing 
medical liability laws in exchange for money.
  In sum, the Pelosi bill will kill jobs, cut Medicare, pile debt on 
our children, increase health care costs, ration care, and raise taxes. 
As a result of these and hundreds of other disturbing provisions, I 
cannot in good conscience vote for the Pelosi government takeover of 
health care.
  Ms. KAPTUR. Mr. Speaker, the Affordable Health Care for America Act 
will strengthen America and offer greater security to our workers, 
families, seniors and businesses. It will enhance our Nation's health 
care system, placing American healthcare consumers where they belong: 
at the heart of it. H.R. 3962 will improve quality, choice and 
competition, while cutting down fraud, waste and abuse, and lowering 
costs over the long term. It will strengthen Medicare, eliminate the 
Part D ``donut hole,'' improve access for lower income citizens so that 
Medicare is affordable for ALL seniors, and create new consumer 
protections for Medicare Advantage Plans. Discrimination for pre-
existing conditions, dropped coverage, and yearly or lifetime caps will 
no longer be tolerated. Co-pays and other cost-sharing for preventative 
services will be eliminated and annual caps on what an individual or a 
family pays out-of-pocket will be established.
  Since 1987, the cost of the average family health insurance policy 
has risen from 7 percent of median family income to 17 percent. Family 
premiums are projected to increase an average of $1,800 each year and 
in 2007, 60 percent of bankruptcies were reported to be related to 
medical costs. With this bill, no American family will go bankrupt 
because they get sick.
  Sixty percent of our Nation's entire uninsured population are small 
business owners and their employees and families. This equals at least 
28 million uninsured Americans. Small business premiums have risen 129 
percent since 2000. In 2008, 38 percent of small companies offered 
health coverage, compared with 41 percent in 2007 and 61 percent in 
1993.
  For too long, the health of our Nation has dwindled while the pockets 
of the insurance giants have thickened. Our seniors have compromised 
prescription drugs for necessary groceries, while the pharmaceutical 
industry has made record profits. Hard working families have watched 
their savings plummet and their homes foreclosed after unexpected 
illnesses. Women with breast cancer, men with heart disease and 
children with leukemia or childhood diabetes have been flat-out denied 
health insurance coverage for pre-existing conditions or reaching 
insurance policy caps.
  Under the House Plan, the Ninth Congressional District of Ohio, the 
region I represent, will benefit immensely and in very specific ways:

[[Page 27503]]

  386,000 residents will see improved employer-based coverage
  167,000 households would be eligible for credits to help pay for 
coverage
  38,000 uninsured citizens just in our region would be eligible for 
insurance under a reformed system
  14,500 small businesses will be allowed to obtain affordable health 
care coverage and 12,400 among them will receive tax credits to help 
reduce the costs of health insurance
  102,000 beneficiaries will benefit from an improved Medicare program
  7,600 seniors will benefit from closing the prescription drug donut 
hole, starting with $500 of cost forgiveness in 2010
  1,700 families will be protected from bankruptcy due to unaffordable 
health care costs
  $120 million in savings will be seen by hospitals and health care 
providers as a result of reductions in uncompensated care.
  Under this bill, immediately, the uninsured and seniors will receive 
relief through a temporary insurance program. Individuals receiving 
COBRA will be allowed to keep their coverage until a more customer 
friendly, one-stop marketplace for health insurance, known as the 
Exchange, is created. The Exchange will offer affordability credits and 
tax credits for individuals and businesses that need them. Health plans 
will be required to allow young people until their 27th birthday to 
remain on their parents' health insurance policy. Moreover, insurance 
companies will be subject to public review and disclosure of insurance 
excessive rate increases.
  Much needed investments will be made right away in training programs 
designed to increase the number of primary care doctors, nurses, and 
public health professionals. Not-for-Profit purchasing collaboratives, 
such as the FrontPath Health Coalition from Northwest Ohio, will be 
strengthened to achieve careful plan management and cost-savings, and 
encouraged as a central provision of Title I. Community Health Centers 
will see an increase in funding to allow for a doubling of patients 
over the next 5 years. A $10 billion fund will be created to finance a 
temporary reinsurance program to help offset the costs of expensive 
health claims for employers that provide health benefits for retirees 
age 55-64.
  The well being of individuals and our nation will benefit from these 
reforms. From an economic standpoint, healthcare costs have stifled the 
vitality of American businesses and their ability to compete in the 
global marketplace. The 129 percent increase since 2000 in small 
business premiums alone have smothered their potential and destroyed 
their ability to cover employees, resulting in an astounding 60 percent 
of our Nation's entire uninsured population.
  Affordable health insurance reform is necessary to cut the costs of 
doing business, reduce the share of government expenditures spent on 
health care, help our companies to be more competitive in the world 
market, unleash the entrepreneurial talents of the American people, and 
give peace of mind to the middle class and our seniors and others that 
everything they have worked for will not be taken away if they get 
sick.
  As someone who grew up in a small business family, I watched our 
father forced to sell our small family grocery when he became ill. He 
needed health insurance for our family and took a job at a local auto 
assembly plant to obtain it for his wife and children. I promised 
myself when I was elected to Congress that passing legislation to cover 
small business would be one of my top priorities. Finally, it has 
become possible to vote on a bill that will do this for millions of our 
fellow citizens.
  With the mounting economic strain on American families and the rising 
costs of health insurance to workers, businesses and federal budget, 
the status quo has proven itself unsustainable, fiscally irresponsible 
and morally unacceptable. The time has come for this historical change. 
I stand in support of its promise to the American people.
  Mr. KUCINICH. Mr. Speaker, we have been led to believe that we must 
make our health care choices only within the current structure of a 
predatory, for-profit insurance system which makes money not providing 
health care. We cannot fault the insurance companies for being what 
they are. But we can fault legislation in which the government 
incentivizes the perpetuation, indeed the strengthening, of the for-
profit health insurance industry, the very source of the problem. When 
health insurance companies deny care or raise premiums, co-pays and 
deductibles they are simply trying to make a profit. That is our 
system.
  Clearly, the insurance companies are the problem, not the solution. 
They are driving up the cost of health care. Because their massive 
bureaucracy avoids paying bills so effectively, they force hospitals 
and doctors to hire their own bureaucracy to fight the insurance 
companies to avoid getting stuck with an unfair share of the bills. The 
result is that since 1970, the number of physicians has increased by 
less than 200% while the number of administrators has increased by 
3000%. It is no wonder that 31 cents of every health care dollar goes 
to administrative costs, not toward providing care. Even those with 
insurance are at risk. The single biggest cause of bankruptcies in the 
U.S. is health insurance policies that do not cover you when you get 
sick.
  But instead of working toward the elimination of for-profit 
insurance, H.R. 3962 would put the government in the role of 
accelerating the privatization of health care. In H.R. 3962, the 
government is requiring at least 21 million Americans to buy private 
health insurance from the very industry that causes costs to be so 
high, which will result in at least $70 billion in new annual revenue, 
much of which is coming from taxpayers. This inevitably will lead to 
even more cost, more subsidies, and higher profits for insurance 
companies--a bailout under a blue cross.
  By incurring only a new requirement to cover pre-existing conditions, 
a weakened public option, and a few other important but limited 
concessions, the health insurance companies are getting quite a deal. 
The Center for American Progress' blog, Think Progress, states ``since 
the President signaled that he is backing away from the public option, 
health insurance stocks have been on the rise.'' Similarly, healthcare 
stocks rallied when Senator Max Baucus introduced a bill without a 
public option. Bloomberg reports that Curtis Lane, a prominent health 
industry investor, predicted a few weeks ago that ``money will start 
flowing in again'' to health insurance stocks after passage of the 
legislation. Investors.com last month reported that pharmacy benefit 
managers share prices are hitting all-time highs, with the only 
industry worry that the Administration would reverse its decision not 
to negotiate Medicare Part D drug prices, leaving in place a Bush 
Administration policy.
  During the debate, when the interests of insurance companies would 
have been effectively challenged, that challenge was turned back. The 
``robust public option'' which would have offered a modicum of 
competition to a monopolistic industry was whittled down from an 
initial potential enrollment of 129 million Americans to 6 million. An 
amendment which would have protected the rights of states to pursue 
single-payer health care was stripped from the bill at the request of 
the Administration. Looking ahead, we cringe at the prospect of even 
greater favors for insurance companies.
  Recent rises in unemployment indicate a widening separation between 
the finance economy and the real economy. The finance economy considers 
the health of Wall Street, rising corporate profits, and banks' 
hoarding of cash, much of it from taxpayers, as sign of an economic 
recovery. However in the real economy--in which most Americans live--
the recession is not over. Rising unemployment, business failures, 
bankruptcies and foreclosures are still hammering Main Street.
  This health care bill continues the redistribution of wealth to Wall 
Street at the expense of America's manufacturing and service economies 
which suffer from costs other countries do not have to bear, especially 
the cost of health care. America continues to stand out among all 
industrialized nations for its privatized health care system. As a 
result, we are less competitive in steel, automotive, aerospace and 
shipping while other countries subsidize their exports in these areas 
through socializing the cost of health care.
  Notwithstanding the fate of H.R. 3962, America will someday come to 
recognize the broad social and economic benefits of a not-for-profit, 
single-payer health care system, which is good for the American people 
and good for America's businesses, with of course the notable 
exceptions being insurance and pharmaceuticals.
  Mr. AL GREEN of Texas. Mr. Speaker, I rise in support of H.R. 3962, 
the Affordable Healthcare for America Act. I would like to thank the 
Democratic Leadership and the Chairmen of the committees of 
jurisdiction for their unwavering commitment to this important cause.
  Today, we are faced with a historic opportunity to accomplish 
meaningful change in the lives of millions of Americans. I am in 
support of this bill because I believe in improving the quality of 
care, the accessibility of care, and the affordability of care. The 
status quo is unsustainable and the cost of inaction is simply too 
high.
  If we pass this legislation, we will reduce the federal deficit by an 
estimated $129 billion over the next ten years. If we fail to do so, we 
will ensure that our country continues to spend $79,274 a second on 
healthcare. We will continue to dedicate 17.6 percent of our gross 
domestic product, or $2.5 trillion a year towards healthcare 
expenditures.

[[Page 27504]]

  To pass this legislation would mean that an estimated 36 million 
Americans would gain access to health insurance; failing to do so, 
would mean that the 45.7 million Americans who cannot afford, or cannot 
gain access to healthcare, would remain without coverage. Among the 
45.7 million uninsured, 1.4 million are children in my home state of 
Texas--this is simply unacceptable.
  Finally, passing this legislation would mean an end to the 
discriminatory practices of the health insurance industry that have 
devastated so many Americans. No longer will people fear having a pre-
existing condition will prevent them from receiving health insurance 
coverage. No longer will families fear the uncertainty of a 
catastrophic health event, or fear being driven into bankruptcy in 
trying to pay for the cost of care. No longer will people have to fear 
losing their health coverage simply for getting sick. In passing this 
legislation, we put an end to the days when 14,000 Americans lose their 
coverage every day.
  The time has come when we, in Congress, are faced with a decision to 
either change the course of this country, to shift its direction 
towards accessible and affordable healthcare, or continue down an 
unsustainable path, one wrought with uncertainty. With so many American 
families struggling to support themselves, I am proud to support this 
legislation.
  Mr. MARKEY of Massachusetts. Mr. Speaker, thank you Speaker Pelosi, 
Chairman Waxman, Chairman Emeritus Dingell, Chairman Rangel and 
Chairman Miller for your leadership in bringing us to this historic 
day.
  For almost a century, we have been laying the groundwork for 
comprehensive health care reform in our country--ever since Theodore 
Roosevelt's Progressive Party included health insurance coverage in its 
platform for the 1912 elections.
  Since then, there has been some progress--Medicare for seniors, 
Medicaid for the poor, CHIP for children,--as well as successful 
efforts in some states, including the landmark health reform law 
enacted in my home state of Massachusetts three years ago. But we have 
continued to come up short. And now the 46 million Americans without 
health care are paying the price.
  Our health care system has been ailing for decades, and now it's in 
intensive care. The consequences of this broken health care system are 
severe--the number one cause of personal bankruptcies today is medical 
bills--Americans going broke when they get sick. And 80 percent of 
these medical bankruptcies strike Americans who actually have 
insurance. It is unconscionable that so many Americans have to fight 
their insurance companies while they fight for their very lives. Their 
insurance policies fail to cover all of the astronomical costs 
associated with their treatment. They are insured, but not covered.
  I recently received a letter from a constituent that illustrates one 
of the reasons why we need health care reform now. Peter returned home 
from the hospital to find a bill informing him that his insurance 
company denied coverage for the anesthesia used during his operation. 
The insurance company deemed the anesthesia ``medically unnecessary'' 
and billed him $10,000.
  He had open heart surgery, Mr. Chairman. So he asked me, did the 
insurance company expect him to ``take a swig of whiskey and bite a 
bullet'' while the surgeon cut open his chest? Unbelievable, Mr. 
Chairman, but true. Like too many Americans, he was insured, but not 
covered. We desperately need health care reform because there are too 
many stories like Pete's all across the country.
  My Republican colleagues want to put a Band-Aid on our badly broken 
system, but what it really needs is CPR--Coverage, Prevention and 
Research. That's exactly what our health bill delivers for the American 
people.
  We expand COVERAGE to ensure that all Americans have access to 
affordable care.
  We invest in PREVENTION to transform our system from a ``sick care'' 
system into a true health care system.
  We support RESEARCH, building on the $10.4 billion down payment in 
the recovery and reinvestment act for NIH. In this bill, we will invest 
in comparative effectiveness research to help improve the quality of 
care and reduce costs.
  The Republicans' plan is really quite simple: You're On Your Own. The 
Republican plan tells Americans--``If you get sick and don't have 
insurance, you're on your own.'' The Republican plan tells Americans if 
you are denied coverage because of a pre-existing condition ``You're on 
your own.'' Republican Leaders in Washington seem to be suffering from 
a pre-existing condition of their own--a heart of stone. If you kicked 
their heart, you'd break your toe! And under the Republican plan, they 
could be denied coverage.
  The Republicans say the Democratic Plan will put the government 
between you and your doctor, but the doctors who make up the American 
Medical Association support the Democratic bill, not the Republican 
Plan. They say it will hurt small businesses but the Main Street 
Alliance, representing thousands of small businesses around the 
country, support the Democratic bill, not the Republican Plan. The 
Republicans claim the Democratic bill will hurt seniors, but the AARP 
has endorsed the Democratic bill, not the Republican Plan.
  There are reasons why the AARP supports the Democratic bill. The 
Democratic bill will close the Medicare part D donut hole, the 
Republican bill does not. We provide support for low-income seniors, 
they do not. We will extend the solvency of Medicare, they do not.
  You know, GOP used to stand for Grand Old Party. Now it stands for 
Grandstand, Oppose, and Pretend. They grandstand with phony claims 
about non-existent death panels. They oppose any real reform. And with 
this Substitute they pretend to offer a solution while really doing 
nothing. GOP--Grandstand, Oppose, and Pretend.
  Make no mistake about it; the Republican substitute is not real 
reform. It does nothing to curb skyrocketing health care costs. It does 
nothing to provide real insurance coverage to millions who are now 
uninsured. It does nothing to stop the unfair practices of insurance 
companies.
  Mr. Speaker, there are too many Americans living in fear of a 
terrorist attack, but not the kind that comes from a gunshot, bomb or 
box cutter. It's the kind that may strike during a phone call from the 
doctor's office or during a check-up when the doctor delivers 
devastating news: ``You have cancer''; ``Your memory loss is early 
onset Alzheimer's''; ``The numbness is Parkinson's''; ``The Lou 
Gehrig's Disease that claimed your grandfather will strike you one 
day.''
  We can fight against the terror of disease by reforming our health 
care system with better coordination, focusing on prevention, and 
ensuring that all Americans have access to quality, affordable care. 
And that's exactly what our bill will do.
  I am pleased that this historic bill includes provisions that I 
authored, including:
  A Medicare program to provide coordinated care to severely ill 
patients by a team of doctors and other health care professionals right 
in the beneficiaries' own homes, allowing these frail Americans to 
remain independent as long as possible.
  A provision to allow patients with rare diseases, like cystic 
fibrosis, to participate in clinical trial research to find a cure for 
their devastating disease without losing eligibility for the Social 
Security benefits they depend on.
  A safeguard to ensure that insurance companies don't game the new 
health care exchange by cherry-picking only healthy individuals.
  Today, we are here to write a new chapter in our century-long effort 
to provide every American with the health care coverage they need and 
deserve.
  Today we can vote for a bill that uses the American values of choice, 
innovation, and competition to address some of our nation's greatest 
challenges--skyrocketing health care costs, millions without health 
insurance, and millions more who are under-insured and struggling to 
pay their medical bills.
  Today we can pass legislation that gives all Americans access to 
quality, affordable health care. I urge my colleagues to vote ``aye'' 
on this bill.
  Ms. HERSETH SANDLIN. Mr. Speaker, I believe it's critical that we 
control rising health care costs, increase quality and value within our 
health care system, and that we improve access to health care and 
affordable health care insurance coverage.
  H.R. 3962, the Affordable Health Care for America Act, represents one 
of the most important votes of the year, on an issue that has been a 
priority for me since I first was given the honor of representing South 
Dakotans in Congress. I have long believed that the strength of our 
communities in South Dakota depends on the health of our people and 
that, unfortunately, quality, affordable care remains out of reach for 
far too many South Dakotans.
  I am convinced this Congress and the President will achieve 
fundamental reform because our country must fix what's broken in our 
health care system. The status quo is unsustainable. There is simply 
too much at stake for South Dakota's families and businesses, who have 
either seen their premiums rise sharply year after year, or who still 
have no access to an affordable plan.
  Done right, health care reform will both ensure that more people have 
access to quality health care, and, just as critically, make the 
common-sense reforms that are necessary to fix an unsustainable system 
that threatens our fiscal future. These twin goals of addressing 
access, quality and costs on the one hand, and solidifying our fiscal 
future on the other

[[Page 27505]]

are not mutually exclusive. In fact, they are complementary.
  Unfortunately, the House bill misses this critical opportunity. While 
it does include many good provisions, it is not the right answer for 
South Dakota, it could threaten existing access to health care in our 
state, and it does not include nearly enough cost-containment and 
deficit reduction measures.
  I am concerned by the projected impact of the bill's Medicaid 
provisions on South Dakota's state budget, and the reductions in 
payments for long-term care under Medicare. I have recently discussed 
the state's budgetary situation with Governor Rounds, along with a 
number of community leaders, business people and others across South 
Dakota, and we must take this situation very seriously. The growth in 
the state Medicaid program due to the recession will produce a 
projected 25 to 30 million dollar deficit in the state Medicaid program 
in 2010, and, after the expiration of the Recovery Act enhancement in 
the FMAP rate, a 50 to 60 million dollar deficit in FY2011.
  Early analysis suggests that the House bill Medicaid provisions would 
impose at least $87.6 million more in new Medicaid costs on the state 
than the Senate Finance Committee bill. Given that budgetary impact, we 
have to consider the likelihood that dramatic service cuts would be the 
end result in South Dakota if the House bill were implemented, and that 
is a source of serious concern for me. It should be for every South 
Dakotan.
  I have discussed the long-term care provisions of the House bill with 
a number of long-term care providers in South Dakota and have serious 
concerns about how the House bill would affect the future of care in 
our state for our seniors. While the original House legislation again 
has been improved in this respect by the addition of some incentive 
payments under Medicaid, overall, I am concerned that the cuts under 
Medicare to long-term care are unsustainable, and put undue financial 
pressure on this essential part of the health care infrastructure of 
South Dakota. Nursing homes will not derive the same benefit from 
universal coverage that hospitals will, so this is another issue that 
needs to be addressed as the process continues.
  Another of my top priorities is the Indian Health Care Improvement 
Act reauthorization that has been incorporated into the broader bill. 
Together with the nine sovereign Native Tribes I represent, I have 
worked hard to advance the Indian Health Care reauthorization in the 
House of Representatives. I share the concerns of the Great Plains 
Tribal Chairman's Association (GPTCA) regarding aspects of the current 
version of that legislation. The GPTCA is comprised by the elected 
leaders of the sovereign Indian Tribes and Nations of the Great Plains, 
including South Dakota. I have consulted closely with the Tribes I 
represent. For years, the Tribes and the GPTCA have supported the 
Indian Health reauthorization and have been disappointed at the great 
length of time it has taken to bring the legislation to this point in 
the House. The GPTCA has reviewed the current version of the Indian 
Health reauthorization contained in the broader health reform bill and 
has serious concerns about certain provisions in the bill, principally 
the fact that urban Indian non-profit organizations are, in various 
sections outside of Title V of the reauthorization, treated on a par 
with federally-recognized tribes.
  The federal government has a unique relationship with the 562 
federally-recognized American Indian and Alaska Native tribes. This 
government-to-government relationship is established by our founders in 
the U.S. Constitution, recognized through, hundreds of treaties, and 
reaffirmed through executive orders, judicial decisions, and 
congressional action. Fundamentally, this relationship establishes the 
responsibilities to be carried out by one sovereign to the other. That 
is why these requests by nine sovereign Sioux tribes located in South 
Dakota are essential. I will continue to provide my full support to 
GPTCA's requests to improve the reauthorization in conference with the 
Senate, and to properly fund Indian health services.
  Turning again to the broader House health care reform bill, 
underlying my concerns relating to Medicaid and long-term care and 
other issues is a fundamental concern about the effect of broader House 
health care reform bill on the nation's long-term deficit, and more 
specifically, my view that it doesn't do enough to start bringing down 
the deficit and health care costs in the long term. As President Obama 
noted earlier this year: ``If we do nothing to slow these skyrocketing 
costs, we will eventually be spending more on Medicare and Medicaid 
than every other government program combined. Put simply, our health 
care problem is our deficit problem. Nothing else even comes close.'' 
He's right. Skyrocketing long-term costs will bankrupt the Medicare 
trust fund by 2017--and that's just part of the problem we need to fix.
  But when it comes to the net change in the federal budgetary 
commitment to health care, the House bill is seven times greater in 
budgetary commitment of dollars than the Senate Finance Committee bill, 
while falling far short of the long-term cost containment in the Senate 
bill. In my view, any bill with such a significant increase should have 
a similar commitment to cost containment. Otherwise, we'll find 
ourselves in the same situation we find ourselves in with Medicare--an 
essential program for South Dakotans that is going broke because we 
can't make the tough choices now and are putting those choices off 
until we face an immediate crisis. That's not reform--that's a recipe 
for fiscal disaster.
  Now, the House bill does include a number of good provisions on which 
the vast majority of South Dakotans I have talked to agree. For 
instance, I strongly support provisions in this bill to require 
insurance companies to cover people with preexisting conditions, and to 
end the insurance companies' ability to cancel coverage when someone 
becomes sick. These practices must end. I was surprised and dismayed to 
see that the House Republican proposal that we also will vote on 
refuses to end the unconscionable practice of denying coverage for 
preexisting conditions. The Congress will ultimately agree on a bill 
that ends this practice. In addition, I support establishing health 
insurance exchanges to provide a transparent and competitive 
marketplace for individuals and businesses to buy more affordable 
health care plans.
  Unfortunately, in my view the House bill has not come far enough from 
where it started, and the bill does not yet represent the right formula 
for South Dakota. Nonetheless, I am very optimistic that, with the 
House and Senate working together with the President, we will achieve a 
good bill for South Dakota during this Congress, because the time has 
come for fundamental reform.
  Again--I believe the Congress has a responsibility to pass health 
care reform legislation that is deficit neutral, that ensures access, 
fairness and affordability of coverage for South Dakotans, and that 
takes a responsible approach to long-term costs with a focus on 
achieving higher quality health care outcomes. This bill meets some of 
these goals but not all, and I can't support it. I remain steadfastly 
committed to improving this legislation and I am optimistic that 
through the legislative process we will achieve what South Dakotans 
deserve, which is a fiscally responsible and sustainable reform of the 
health care system that will dramatically improve coverage and quality 
for all.
  Mr. JORDAN of Ohio. Mr. Speaker, many of my colleagues from across 
the aisle have called this an historic day.
  I wish it was an historic day!
  I wish this was the day that the majority in Congress sat up and 
listened to the American people . . . not just the tens of thousands 
that stood at the steps of our Capitol to speak out in defense of 
protecting their health care . . . but the millions from around the 
country who called our offices, wrote letters to their newspapers, 
spoke at town hall meetings . . . or marched on Washington.
  If they did, they would hear their deep and abiding concern for what 
will happen to their health care if this bill passes.
  What will happen to the relationship between them and their family 
and their doctor when the heavy hand of government gets involved in 
medical decisions?
  What will happen to seniors, and everyone taking care of their 
elderly parents or in-laws, when the overpromise of ``free health 
care'' meets the economic reality of ``rationed care'' when the federal 
government runs short on money?
  What happens to Medicare Advantage customers whose services will be 
cut?
  What happens to those using Health Savings Accounts whose health 
freedoms will be infringed upon?
  What happens to the small business owner who desperately wants to 
hire back some employees or expand his business to provide more 
economic opportunities in his community? What happens when these 
individuals, upon whose success our nation will rise from this 
recession, have to pay the hundreds of billions in new taxes to pay for 
the massive government expansion in this bill?
  Mr. Speaker, how bad does it have to get? How bad does it have to get 
before this Congress starts acting in a way that will help families, 
create jobs, and leave a better America for our children and 
grandchildren?
  How bad does unemployment have to get? Earlier this week, it was 
announced that our nation has reached an unemployment rate of

[[Page 27506]]

10.2 percent, which is the highest unemployment rate in almost 30 
years. Yet studies suggest that the taxes, mandates, and federal 
expansion in this bill will cost our nation another 5.5 million jobs in 
the private sector.
  How bad does the deficit have to get? This year's deficit of over 1 
trillion dollars was the highest in history. Yet this multi-trillion-
dollar expenditure to take over the nation's health care system will 
explode the deficit, despite the fuzzy math that we've heard from the 
other side of the aisle.
  The debt . . . it has reached a nearly insurmountable level of 12 
trillion dollars. How bad does it have to get? Even without the massive 
uncontrolled expenditures involved with this health care bill, the 
national debt is projected to surpass the size of our economy in the 
next few years. Since when has the answer to an exploding national debt 
been an explosive expansion of federal government spending in areas 
that have always been a part of the private sector economy?
  The one positive thing I can say about this bill is the pro-life 
victory we won with the amendment offered by my fellow pro-life 
colleagues, led by Mr. Stupak and Mr. Pitts. I was proud to support 
that amendment because it honored the fundamental truths that life is 
sacred, life should be protected, and taxpayer money should never be 
used to take the life of an unborn child.
  But Mr. Speaker, the bottom line is this: H.R. 3962 is the wrong 
answer to what ails America's health care system.
  It is too expensive. It raises taxes. It expands the reach of the 
federal government into the personal health care decisions that should 
be left between patients and their doctors. It is a job killer. It will 
cause millions of Americans to lose their coverage, while expanding 
coverage to millions of illegal aliens.
  Despite the newly-enacted pro-life protections that I fought so hard 
to enact both in this bill and every relevant piece of legislation 
before this House, it is a bad bill.
  Let me close here. We are blessed to live in the greatest country in 
history. Our country is great, in part, because of something called the 
American Dream. We're a country where people, through their own hard 
work, can pull themselves up and reach for their goals and dreams.
  Mr. Speaker, the American Dream happens because generations of 
parents have worked hard and sacrificed so their children can have life 
a little better than they did. When their children become parents, they 
sacrifice for their children, and the dream lives on.
  This bill is just another example in the recent years of our country 
of borrowing for now and sending the bill to the next generation.
  If we want the American Dream to live on, we must reject this bill 
and return to the American principles that made our nation that shining 
city on a hill.
  Ms. ROYBAL-ALLARD. Mr. Speaker, I rise in support of H.R. 3962, the 
Affordable Health Care for America Act, a bill that is undoubtedly the 
most important single piece of legislation being considered by this 
111th Congress, and possibly by any Congress in the last decade.
  I commend Chairman Waxman from the Energy and Commerce Committee, 
Chairman Miller from the Education and Labor Committee, and Chairman 
Rangel from the Ways and Means Committee, and all of their dedicated 
staff who have invested so much time and energy into crafting a bill 
that addresses the complex and vast failures of our current health care 
system.
  This has been without a doubt the most transparent and inclusive 
legislative effort that I have seen in my seventeen years in Congress, 
and I commend Speaker Pelosi for her tenacious leadership in bringing 
this bill to the floor.
  The Affordable Health Care for America Act is not a perfect bill. 
With an issue that impacts so many stakeholders, and involves so many 
competing interests, it is doubtful any single legislative effort could 
ever satisfy everyone and address all the problems.
  But the fact of the matter is that we cannot afford to do nothing. 
Study after study has shown that under our current system things will 
get worse unless we act now. If we are not successful in passing this 
health reform bill, Americans face a 50-50 chance of losing their 
insurance in the next 10 years, the average family will have their 
already prohibitive health costs increase an average of $1,800 each 
year, and the rising price of medications may become unaffordable even 
for those with insurance.
  H.R. 3962 will help end this cycle of skyrocketing health care costs 
and represents a milestone in our nation's history by finally framing 
healthcare as a universal right for all Americans. With the passage of 
this bill we will improve the quality and affordability of health 
services, prioritize prevention and the reduction of health 
disparities, and take the necessary albeit difficult steps to rein in 
the escalating costs of health care in this country.
  I will vote for H.R. 3962 for many reasons. The most important is 
that it will provide access to affordable health care to the millions 
of uninsured individuals in this country. In my 34th Congressional 
District of California, where the average annual household income is 
less than $36,000, and where forty per cent of my constituents are 
currently uninsured, this bill will provide access to health care for 
240,000 more people.
  The bill also helps families in our country who have health 
insurance, but are struggling with high premiums and uncovered health 
care costs. Last year 1,120 families in my district were forced to file 
health care-related bankruptcies. H.R. 3962 will protect individuals 
like them from catastrophic out of pocket costs through an annual 
allowable personal expense cap.
  This bill will protect our seniors from the Medicare Part D donut 
hole by reducing 5 percent of the cost for brand name drugs and 
gradually eliminating the donut hole altogether. This will be extremely 
beneficial for the 4,100 seniors in my district who each year hit the 
Medicare Part D donut hole requiring them to pay the full cost of 
medications they can't afford.
  H.R. 3962 will help make small businesses more competitive in 
providing health insurance to their employees by providing tax credits 
up to 50 percent of the cost of the insurance. In my district 
approximately 15,000 small businesses would qualify for these credits.
  As chair of the Congressional Hispanic Caucus Health Task Force, I 
commend the Affordable Health Care for America Act for its efforts to 
reduce health disparities and improve minority access to culturally and 
linguistically competent health care. The bill expands Community Health 
Centers which have been a cornerstone of primary care services in 
communities of color, and incorporates critical health disparities 
language guided by the Health Equity and Accountability Act of 2009. In 
addition, the Manager's Amendment strengthens the focus of eliminating 
health disparities by codifying the Office of Minority Health and 
establishing Minority Health Offices across all Department of Health 
and Human Services agencies.
  As co-chair of the Congressional Study Group on Public Health, I am 
particularly pleased that the Affordable Health Care for America Act 
finally prioritizes prevention and public health in this country. The 
bill ensures full coverage of evidence based preventive health 
services, and establishes a Public Health Investment Fund that will 
support core public health infrastructure, help finance the delivery of 
community-based prevention and wellness services, and provide grants to 
train the next generation of Public Health workforce professionals.
  Mr. Speaker, I fully believe that the Affordable Health Care for 
America Act is a bill that will transform our healthcare system and 
will play a determining role in the collective health and fiscal 
viability of our region, our state, and our nation.
  I urge my colleagues to join me in voting yes for this bill today, to 
ensure that our families and communities will have the promise of a 
healthier tomorrow.
  Mr. VAN HOLLEN. Mr. Speaker, we are taking a historic and very 
important step today to lower health care costs for American families 
and small businesses, and fix a broken health care system.
  In considering the Affordable Health Care for America Act, this has 
been one of the most open and transparent debates in Congress. There 
have been countless hours of hearings and mark-ups and more than 3,000 
public health care events around the country.
  The Affordable Health Care for America Act contains significant 
protections that will provide health care consumers greater stability, 
lower costs, and improved quality--while all at the same time paying 
down the deficit. According to independent analysis conducted by the 
non-partisan Congressional Budget Office, the bill reduces the deficit 
by $109 billion over the first 10 years. And it will continue to reduce 
the deficit over the second 10 years.
  This legislation will help the middle class by providing stable, 
affordable health insurance that people can count on. It will rein in 
health care costs for families, businesses and the government. It will 
ensure that if you lose your job, you won't lose your access to health 
care. No one should have to worry about whether they can see a doctor 
when they're sick because they don't have health insurance.
  I have heard from countless constituents who have been victims of 
discrimination by insurance companies, like the family who recently 
shared their experience with me about their inability to obtain health 
insurance coverage. The father started his own company and applied for 
health insurance for his family,

[[Page 27507]]

but three out of the four family members could not be fully covered due 
to pre-existing conditions. It turns out that he was rejected for 
coverage because he had two chest colds in the last 6 years and scar 
tissue in his lungs. For his daughter, the insurance company would only 
issue a policy that precludes coverage for any injury to any part of 
her back at any time in the future because of a previous injury of her 
back. And the same company refused to cover any injury to his son's 
knee at any time in the future from any cause due to a previous injury. 
It is unconscionable that the insurance company's policies precluded 
everyone in his family from being fully covered.
  There are a number of provisions that would help this family, my 
constituents, and millions of Americans. Among them, the bill would end 
the practice of discriminating against those with pre-existing 
conditions, such as diabetes, cancer, a heart condition, or previous 
injuries. It would prohibit insurance companies from dropping health 
care coverage because you became sick. The bill eliminates co-pays for 
preventive and wellness care, and it places annual caps on what 
Americans pay out-of-pocket for health care services. And there would 
be no yearly or lifetime cost caps on what insurance companies cover.
  A critical piece of this legislation is the creation of a new Health 
Insurance Exchange that will allow individuals and small business to 
comparison shop for affordable and quality health insurance coverage. 
The Exchange will help reduce the growth in health care spending by 
encouraging competition on price, quality, and transparency among a 
number of private health insurance companies and a public health 
insurance option. The public option will add choice to the health 
insurance market and participation is completely voluntary. That is why 
Consumers Union and Consumer Reports endorsed this bill. With this 
health care reform bill, Americans will have the freedom to keep their 
doctor or select another one. The choice is theirs. It preserves and 
strengthens the doctor-patient relationship. That's why the doctors of 
America under the umbrella of the American Medical Association have 
endorsed this bill.
  The legislation takes steps to preserve and strengthen Medicare for 
today's seniors and future generations of retirees. For over 40 years, 
Medicare has been a stable, reliable program for senior citizens and 
people with disabilities. It provides health care coverage to 
approximately 45 million Americans. This bill will ensure that seniors 
can see their doctor of choice or find a doctor by improving Medicare 
reimbursement to doctors. It lowers drug costs for seniors by closing 
the Medicare Part D ``doughnut hole'' and allowing the government to 
negotiate with pharmaceutical companies for lower drug prices. And it 
takes steps to reduce waste, fraud, abuse, and inefficiency in the 
Medicare program. For all these reasons, AARP has endorsed this bill.
  Thousands of small businesses in America will benefit from this bill 
because it will provide them greater affordability. Small businesses 
will gain access to the new Health Insurance Exchange that will allow 
them to obtain rates normally enjoyed by larger employers, lower 
administrative costs, greater transparency, and greater choice of plans 
for their employees. They will benefit from increased competition for 
better prices as well as tax credits for those who choose to provide 
health insurance for their employees.
  I am pleased that this bill contains several provisions I helped 
author. The first, the Assessment of Medicare Cost-Intensive Diseases 
and Conditions, directs the Department of Health and Human Services to 
conduct an assessment of the diseases and conditions that are the most 
cost-intensive for the Medicare program. Part of our effort to reform 
the health care system is to develop cures and treatments for those 
conditions and diseases that have a high cost, and this will go a long 
way in that endeavor.
  The second, which I worked on with Representative Kathy Dahlkemper 
and others, requires health insurance plans to allow young people 
through age 26 to remain on their parents' insurance policy, at the 
parent's choice. Young adults between the ages of 19 and 29 are one of 
the largest segments of the American population without health 
insurance, comprising 29 percent of the total number of uninsured 
Americans.
  I am also pleased that we were able to include a provision that ends 
the special advantages for health insurance companies. For far too 
long, the health insurance industry has been exempt from the antitrust 
laws that govern most other businesses. They have abused that benefit. 
I believe it is long past time to repeal this exemption. By ending this 
antitrust exemption, we are increasing competition and preventing 
unfair business practices that allow health insurers to drive up the 
cost of health care.
  Lastly, I worked with Representatives Himes, Bean, and others to 
include in the bill a provision that would allow the creation of state 
health insurance compacts. This would permit states to enter into 
agreements to allow for the sale of health insurance across state 
lines. The creation of state health insurance compacts is another 
element of the health reform bill that will allow consumers to shop for 
insurance across state lines, promote choice and competition, and 
ensure strong consumer protections.
  On the question of whether any of the insurance plans offered in the 
Health Insurance Exchange could cover an abortion, I support the 
provisions in the Rule that created a mechanism for ensuring that no 
public subsidies would go to pay for abortions. The non-partisan 
Congressional Research Service analyzed that provision and found that 
it prevented taxpayer dollars from going to pay for any coverage of 
abortions. The amendment offered by Representative Stupak goes much 
further. It would effectively prevent Americans from using their own 
money to purchase an insurance plan in the Health Insurance Exchange 
that includes coverage of abortions. That would be a dramatic break 
with the current practice where most insurance plans provide for such 
coverage for individuals who choose such plans. Because the Stupak 
amendment would effectively prohibit individuals from using their own 
money to purchase such plans in the Exchange, I oppose it.
  Mr. Speaker, today we stand at a historic crossroads. We can choose 
the road that dead-ends in the status quo--where the health insurance 
industry continues to call the shots and ration our health care--or we 
can pass this legislation and take the path that leads to a future 
where every American has access to affordable, quality health care.
  Now I understand why the health industry is opposed. But our job is 
not to protect the profits of the insurance companies. Let's not 
protect special interests and the status quo. Let's move America 
forward. Let's vote yes for America.
  Ms. CORRINE BROWN of Florida. Mr. Speaker, like the majority of 
Americans, I am well aware of the desperate need in our country for 
comprehensive health care reform. In fact, the immediate need for 
reform became crystal clear to me when, over the August district 
period, I went to a hospital in Jacksonville to visit a friend. This 
friend, who had worked in the Duval County school system for over 25 
years, had lost his job, was without health insurance, was struggling 
to support himself, and had no idea how he was going to be able to pay 
the hospital bill. For the many, many Americans who find themselves in 
similar situations: for the woman who cannot get insurance coverage 
because she is diabetic and has a pre-existing condition, to the one in 
nine children in America without health care, to the millions of middle 
class American citizens who skip necessary treatments because they 
cannot afford it, it is for them that the Affordable Healthcare for 
America Act, which will ensure that all Americans are covered and have 
access to affordable care, is necessary.
  Unfortunately, the bill passed the House without any Republican 
support. Although many pieces of legislation this session have advanced 
in a bipartisan manner, particularly in my committees of 
specialization, Veterans Affairs and Transportation, health care has 
not been an issue of biparty agreement. In 2003, the Republican Party 
pushed through a horrible Medicare Prescription drug law that was voted 
along party lines, in which the Republicans included a ``donut hole'' 
provision, in which there is a wide gap in coverage that forces the co-
payer to pay for much of their own prescription drug costs. 
Fortunately, the bill on the Floor today will begin to close this 
loophole. Similarly, today's bill in the House as well as the Senate 
health care bill, are advancing without any Republican support. Social 
Security was created in 1935 by Franklin D. Roosevelt as part of the 
New Deal, Medicare, in 1965, and Medicaid, in 1965, through Title XIX 
of the Social Security Act. All of these programs were created by 
Democrats without the votes of the majority of Republicans.
  One aspect of health care reform of utmost importance to me is 
maintaining proper funding for Disproportionate Share Hospitals (DSH), 
like Shands Jacksonville (and Gainesville), who provide healthcare to 
uninsured and/or individuals with limited incomes. Disproportionate 
Share Hospitals are invaluable, as they are the one true safety net for 
the working poor nationwide. I fought hard to keep DSH funding in the 
Budget Reconciliation negotiations during the Clinton years, and have 
been working throughout the entire process to ensure that their funding 
was not stripped in the health care bill before us today.
  Another extremely important issue addressed in this bill is that it 
prevents insurance

[[Page 27508]]

companies from denying people coverage based on pre-existing medical 
conditions. Indisputably, denying a health insurance plan to someone 
merely because they're likely to need a particular form of medical care 
runs contrary to the underlying reason for providing medical insurance 
and medical care in the first place. So the bill before the House today 
opens doors to quality medical care to those who were shut out of the 
system for much too long, and also makes prevention a key piece of this 
legislation's goal, since it puts a renewed emphasis on preventive 
care, expands access to screenings and other treatments, and even 
promotes wellness in the workplace.
  Indeed, for nearly a century leaders from all over the political 
spectrum, beginning with President Theodore Roosevelt, have called and 
fought for health care and health insurance reform. Finally today, the 
House of Representatives, the People's House, is about to deliver on 
the promise of making affordable, quality health care available for all 
Americans,
  The Affordable Health Care for America Act is founded on key 
principles of American success: opportunity, choice, competition, and 
innovation. Among the many positive things this bill does, a few items 
that stand out is that it will provide coverage to nearly all our 
nation's citizens, while at the same time reducing the deficit by $32 
billion over the first 10 years. It will also require the Secretary of 
Health and Human Services to negotiate drug prices for Medicare 
beneficiaries; begin to close the prescription drug ``donut hole'' 
immediately; create a new, voluntary insurance program to make long-
term care more affordable; and repeal the anti-trust exemption for 
health insurance companies.
  For Floridians in particular, where more than one in five residents 
do not have health insurance, and for my constituents in Florida's 
third congressional district and minority communities nationwide, the 
need for health care reform is obvious. For the African American 
community and Hispanics, groups who make up nearly half of the 
estimated 50 million Americans who lack insurance, this is imperative. 
In addition, health care costs have become outright unsustainable, and 
experts predict that in the near future, one-fifth of our nation's GDP 
will go towards health care spending.
  The benefits for my district, Florida's third, are numerous. In fact, 
the Affordable Health Care Act will: Improve employer-based coverage 
for 300,000 residents; provide credits to help pay for coverage for up 
to 192,000 households; improve Medicare for 93,000 beneficiaries, 
including closing the prescription drug donut hole for 6,600 seniors; 
allow 20,100 small businesses to obtain affordable health care coverage 
and provide tax credits to help reduce health insurance costs for up to 
18,400 small businesses; provide coverage for 138,000 uninsured 
residents; protect up to 1,400 families from bankruptcy due to 
unaffordable health care costs; reduce the cost of uncompensated care 
for hospitals and health care providers by $145 million. For too long, 
health care has been a privilege, not a right in America. And for years 
our nation's leaders have fought to bring the promise of quality, 
affordable health care to every American.
  Today is a groundbreaking moment in this historic effort. Indeed, we 
are now closer than ever to guaranteeing every American access to 
quality, affordable health insurance and giving middle-class families 
and businesses relief from crushing costs, while simultaneously 
reducing our nation's deficit.
  Ms. McCOLLUM. Mr. Speaker, today we are making history. Today the 
U.S. House of Representatives is making health care in the United 
States of America more affordable and more accessible for millions of 
our citizens. This legislation may not be perfect, but it is very good. 
It will make our country stronger, our economy more productive, and 
every American family healthier.
  Our goal is to achieve universal coverage so that every Minnesotan 
and every American has the ability to access quality, affordable health 
care. The Affordable Health Care for America Act (H.R. 3962) comes 
closer than ever before to realizing that goal by extending health 
insurance coverage to 96 percent of Americans.
  This bill will have immediate and lasting benefits for millions of 
Americans. It will give families the confidence and security that comes 
with knowing they will be able to access quality, affordable health 
care when they or a family member is sick. And it places affordable 
health care coverage within reach for millions of American families who 
are asking for our help.
  As I have often said, I believe that health care should be a right 
for all Americans. Critics of making health care a right often say we 
already have universal health care since people can go to the emergency 
room and access care if they really need it. This flawed logic is the 
best example of why I believe health care in America is broken and must 
be fixed.
  Our health care system is broken when we live in the wealthiest, most 
powerful country in the world, but health care is a privilege available 
to only those with enough money to afford insurance and for those of us 
fortunate enough to have a job that provides health insurance.
  Our health care system is broken when 60 million people in this 
country have no health insurance coverage or are under-insured--more 
than 85 percent of whom are from working families.
  Our health care system is broken when families are forced to postpone 
or skip necessary care because premiums have increased more than 90 
percent in the last nine years for Minnesota families.
  Our health care system is broken when our country spends $2.4 
trillion a year for health care--almost twice as much per person as any 
other country--but we rank 37th in the world in health care outcomes.
  Our health care system is broken when you can be denied coverage for 
being sick, for having a baby, or for suffering from domestic violence.
  Our health care system is broken when 45,000 people die in the United 
States each year because they lack health insurance and cannot access 
needed care.
  We can and must do better. Today we have an opportunity to save these 
lives and make affordable health care insurance a reality for every 
American.
  My constituents and all citizens across this country need to know 
what is in this bill to help American families and workers. This 
legislation will make quality health care more affordable and more 
accessible for every patient. It will protect families from falling 
into bankruptcy due to unaffordable costs by limiting out-of-pocket 
costs, lifting lifetime limits on coverage, and lowering premiums.
  First and foremost, if you love your doctor and like your current 
insurance, you are free to keep what you have. This legislation does 
not require you to make any changes. Yet, the ranks of the insured are 
shrinking more every year and the numbers of satisfied citizens are 
falling. Millions of Americans have too little insurance, too few 
choices, and no options left. For those Americans--for most Americans--
this legislation is a lifeline to the security they have longed for and 
long-deserved.
  This bill will give every American the peace of mind that insurance 
companies can no longer deny coverage for pre-existing conditions, or 
cancel your coverage when you are sick and need it the most.
  It includes a competitive public insurance option to guarantee that 
Americans will have an affordable choice among insurance providers and 
keep private insurers honest.
  It improves health care for patients and their families by making 
investments to increase the number of providers, improve access to 
primary care, and support a patient-centered approach that focuses on 
quality and emphasizes prevention.
  For our seniors, this legislation will strengthen Medicare by 
eliminating the waste, fraud and abuse that diverts health care dollars 
away from care and into the pockets of crooked companies. It will 
immediately begin closing the ``donut hole'' in the Medicare 
prescription drug benefit to make prescriptions more affordable. And it 
will ensure the financial stability and solvency of Medicare for 45 
million seniors.
  For our children, it will help expand coverage and ensure that the 
youngest Americans receive quality coverage that includes essential 
benefits such as vision and oral services. And it will extend coverage 
for young people by allowing them to remain on their parent's insurance 
until their 27th birthday.
  The Affordable Health Care for America Act does all these things 
while meeting President Obama's call for new costs to be covered. In 
fact, the bill goes much farther by reducing the deficit by $109 
billion over the next 10 years.
  This comprehensive health care legislation is ambitious by necessity. 
I have confidence every one of these reforms will be implemented 
successfully because of what my state of Minnesota has accomplished. 
Through a combination of smart investments and an enduring commitment 
to care for all of our friends and neighbors, my state proved a high-
quality, low-cost health care system is possible. Minnesota is 
consistently ranked among the highest in the nation for quality of care 
and rates of insured citizens--almost 92 percent. And Minnesota attains 
these high standards with some of the lowest costs in the country.
  Unfortunately, our state is forced to work with fewer resources than 
most other states because of the Medicare geographic payment disparity. 
Medicare's outdated and unfair reimbursement system pays Minnesota 
doctors

[[Page 27509]]

and hospitals at some of the country's lowest rates, despite the fact 
they produce some of the country's best patient outcomes. The current 
system rewards the amount of services provided rather than the quality 
of care patients receive.
  Patients, providers, health plans, hospitals, and unions have all 
told me that ending this disparity and reversing this flawed incentive 
structure is the most important issue for Minnesota in the national 
debate on health care reform. While Minnesota's health care system is 
excellent today, the broken Medicare payment system threatens to 
undermine it in years to come.
  This health care reform legislation is our last best chance to fix 
this problem, achieve fairness for Minnesotans, and make evidence-
based, quality care the standard wherever you live in the United 
States. That is why I worked to unite 40 of my House colleagues who 
represent 17 different states in a new Quality Care Coalition. Together 
with my coalition co-chairs Representatives Bruce Braley, Ron Kind and 
Jay Inslee, we created the political will we have always needed but 
never had to address this problem. After more than 20 coalition 
meetings over the course of 6 months and a series of intensive 
negotiations with House Leadership, our coalition secured an agreement 
to end the unfair treatment of high quality, low-cost states such as 
Minnesota. And by securing fairness for our states, we will be helping 
to deliver better quality for all patients in every state.
  This agreement places America on a path to reward high quality, 
evidence based, cost-effective health care by making fundamental 
improvements in the delivery system. H.R. 3962 directs the highly-
regarded Institute of Medicine to develop recommendations on how to 
modernize the Medicare payment system so it rewards value and quality. 
This will transform the Medicare payment system to ensure better care 
for patients and reduce health care costs over the long-term, and will 
help secure a better future for our patients, families, and seniors.
  While the legislation we vote on today would make unprecedented 
reforms, I will continue working to improve the bill before it returns 
to the House for a final vote. To be truly comprehensive, health care 
reform legislation must reach all Americans, including the 15 million 
citizens employed in the nonprofit sector. Achieving parity between 
small nonprofit and for-profit employers in this legislation is one 
item of unfinished business. I am also concerned with the burden this 
bill places on the medical device industry to generate revenue and 
potentially negative impact such a tax would have on patients, workers, 
and small businesses. I look forward to working with House Leadership 
and the conference committee to help address these issues and 
strengthen this legislation.
  Still, H.R. 3962 remains a historic achievement. This legislation 
addresses the needs of Minnesota's families and families across this 
country. It modernizes Medicare and covers the uninsured. It invests in 
prevention instead of paying for disease. For these reasons and many 
more, the Affordable Health Care for America Act has the support of 
over 300 state and national organizations. These supporters include the 
American Nurses Association, American Medical Association, SEIU, AFL-
CIO, and AARP. Organizations representing millions of Americans back 
this legislation because they know our health care system is broken and 
change cannot wait another year.
  Still, there are critics of health care reform that are fighting 
desperately to maintain the status quo. It is disappointing to see 
Republicans choose health care profiteers and insurance companies over 
reforms that Americans need and want. My Republican colleagues have 
offered politics and posturing but no real solutions. They have no 
serious alternative to H.R. 3962 to control costs, expand access and 
improve quality. They have made killing health reform and killing 
America's chance at achieving health reform their only goal. The 
American people deserve better.
  I would like to thank Speaker Pelosi, Majority Leader Hoyer, Majority 
Whip Clyburn and Caucus Chair Larson for their extraordinary leadership 
to bring affordable, quality health care to all Americans. Thanks are 
owed to the three committee chairmen--Chairman Waxman, Chairman Rangel, 
and Chairman Miller--who held dozens of hearings throughout the year 
and crafted a historic bill. I would also like to thank Chairman 
Dingell for his dedicated service in introducing health care 
legislation for over 50 years to bring health care coverage for all 
Americans.
  I would especially like to thank Speaker Pelosi for her attention to 
the concerns of the Quality Care Coalition and all of the diverse 
interests of the Caucus. Vice Chairman Becerra also has my gratitude 
for the vital role he played in negotiating this agreement to move 
health care reform toward high quality, cost-effective care.
  Today is a historic step toward making health care reform a reality, 
but it is not the end. I urge the Senate to stay focused and committed 
so an equally strong bill meets H.R. 3962 in conference committee. I am 
committed to sending a health care bill to the President's desk that 
will bring meaningful reform for American families, seniors and 
businesses. With passage of this legislation, health care will no 
longer be a privilege for those who can afford it.
  I urge my colleagues to support H.R. 3962 and guarantee that 
affordable, quality health care will be accessible for every Minnesota 
family.
  Mr. McCAUL. Mr. Speaker, in the 72 hours we were allowed, Republicans 
weeded through thousands of pages of bureaucratic provisions, mandates, 
programs and spending. Despite its monstrous size, this health care 
takeover has come down to a few clear, evident points: it raises taxes, 
raises premiums, increases health care costs, and dumps trillions of 
dollars of debt on our children and grandchildren. Small businesses and 
families will bear the weight of this bill for generations.
  We all agree that health care reform is urgently needed, but this 
bill destroys the American health care system as opposed to improving 
it. Instead of incentivizing the private market to offer more 
affordable health care coverage options, it punishes small businesses 
and their employees. It threatens jail time for individuals who do not 
purchase insurance and could soon lead to the rationing of care, 
depriving Americans of life-saving treatments that are not deemed 
``cost-effective.'' Even doctors, the most experienced in this health 
care debate, oppose this proposal and have shared concerns of the many 
clinics and hospitals that will be forced to reduce or deny services.
  The over 2,000 page spending plan imposes nearly $800 billion in new 
taxes on individuals, families and small businesses. It places mandates 
on both individuals and employers which, according to the President's 
Economic Advisor, will result in the loss of up to 5.5 million jobs. 
These mandates will also discourage the hiring of low-wage and minority 
workers. In the face of both a recession and a 10.2% unemployment rate, 
Speaker Pelosi's unprecedented tax-and-spend approach will come at the 
expense of American citizens.
  Moreover, while the majority of Americans are happy with their health 
care coverage, an estimated 114 million Americans will lose their 
insurance under Speaker Pelosi's plan and be dumped into the 
government-run option. The plan also cuts more than $170 billion from 
Medicare Advantage plans, jeopardizing millions of seniors' existing 
coverage. The bill puts the government in the middle of Americans' 
personal health care decisions, as opposed to reform based on improving 
the quality and affordability of health care.
  While Democrats have continually touted the benefits of a public 
option, they themselves voted against an amendment to require 
enrollment for Members of Congress. This speaks volumes to the true 
quality of a government plan, as what I view as adequate coverage for 
the American public would also be adequate for my family. Furthermore, 
the bill also abolishes the private health insurance market, forcing 
all individuals to purchase coverage through a government-controlled 
Exchange and eliminating choices from the health care system. While 
this bill takes care of Members of Congress, it eliminates the freedom 
of choice for the American public.
  Republicans have introduced numerous bills to provide improvements in 
the cost and delivery of health care, but we have been denied a seat at 
the table. Behind closed doors, the Democrats crafted a monstrosity of 
a bill to take over one sixth of the economy, and then limited floor 
debate to four or five hours on one of the most sweeping pieces of 
legislation we have ever seen.
  The Republican alternative provides a common-sense approach to the 
main problems in our health care system. It would lower premiums, 
decrease health care costs, reign in federal spending, and allow for 
more options, choice, and innovation in the health care system.
  The non-partisan Congressional Budget Office has estimated that 
average premiums under the Republican alternative would be almost 
$5,000 less than under the Democratic plan in 2016. It would provide 
incentive grants for states to further lower premiums, and allow 
businesses to innovate ways to promote health and wellness and curb 
health care spending. The alternative would also expand high risk 
pools, prohibit insurance companies from denying individuals with pre-
existing conditions, and ensure inter-state purchasing of

[[Page 27510]]

health insurance. These reforms would drive down the costs of health 
care to make it more affordable for Americans while also protecting the 
choice and numerous options that citizens need.
  I have spoken to many health care professionals in my District as 
well as held town halls with my constituents, and both have expressed 
not only their opposition, but their fear, of this government takeover 
of health care. We are not listening to Americans, and we are missing 
the opportunity to use insight from the experts in the field to enact 
meaningful reform. This bill is not what Americans have asked for.
  Mr. PLATTS. Mr. Speaker, I rise today in opposition to Speaker Nancy 
Pelosi's health care bill (H.R. 3962). I plan to vote against this 
legislation for numerous substantive reasons, including my concerns 
about its trillion dollar plus cost to taxpayers, its mandates on 
individuals and employers, its deep cuts to Medicare, and the strong 
likelihood that H.R. 3962's provisions will cost millions of Americans 
their jobs. H.R. 3962 is a health care bill that fails to abide by the 
physician's guiding principle: ``First, do no harm.''
  H.R. 3962 consists of approximately 2,000 pages and costs more than 
$1 trillion over ten years. If adopted, this legislation will destroy 
millions of jobs by raising taxes on small businesses and other 
employers. H.R. 3962 also imposes new taxes on certain employer-
provided health benefits and on medical devices such as wheelchairs and 
walkers. In total, H.R. 3962 includes more than $700 billion in new 
taxes.
  Unbelievably, in the name of health care reform, H.R. 3962 cuts 
Medicare benefits by more than $400 billion and raises Medicare 
premiums, making access to comprehensive health care more difficult for 
our Nation's senior citizens. Additionally, over time, H.R. 3962 will 
move countless Americans involuntarily from private health insurance to 
government-run health care.
  I have long maintained that there is no ``silver bullet'' for health 
care reform. We should aim to build upon the current health care system 
in a variety of ways, making health insurance more affordable and more 
accessible. In other words, Congress should fix what is broken in our 
nation's health care system and be certain not to break what is not.
  Congress should adopt insurance reforms to end the practice of 
denying coverage due to pre-existing conditions and ensure the 
portability of one's health insurance. Additionally, Congress should 
allow small businesses to band together to negotiate insurance coverage 
for their employees, just as large corporations and labor unions are 
already allowed to do. Congress should also allow individuals to 
purchase health insurance across state lines from a competitive, 
nation-wide market and should enact responsible medical malpractice 
reform to lower health care costs. I plan to join with my fellow 
Republicans in voting for an alternative legislative proposal that 
includes such reforms.
  The full Senate has yet to act on a health care bill of its own. 
Hopefully, when it does so, the Senate will adhere to the principle of: 
``First, do no harm.''
  Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I rise on behalf of 
the nearly 50 million Americans who don't have health insurance.
  On behalf of parents who have to choose between taking their sick 
child to the doctor and paying the electric bill on time.
  On behalf of adult children who are slowly losing their parents to 
Alzheimer's, and yet can't afford the quality care their parents need.
  In a Nation as prosperous as ours, it is a shame and a tragedy that 
so many families suffer, watching their loved ones die, when timely 
tests or early care could have prevented it.
  American families have waited too long for the freedom and security 
that universal healthcare can provide.
  I strongly support H.R. 3962, the Affordable Health Care for America 
Act because this legislation tells families yes.
  Yes, they can afford high quality health care.
  Yes, they can get health insurance even if they have a pre-existing 
condition.
  Yes, they can expect to be treated fairly by insurance companies, 
regardless of their gender or age. Yes, they can keep their health 
insurance, even if they get sick.
  And yes, we can pass health reform that protects and strengthens our 
economy by encouraging development and use of health information 
technology, generic drugs, and advanced medical devices.
  It's well past time for Congress to make sure that an unforeseen 
illness or accident doesn't mean economic ruin for American families. 
To stop the abuses of health insurance companies, who play games 
instead of paying for health care. To ensure that Americans have the 
freedom to change jobs or to become entrepreneurs, instead of being 
locked into a job they hate because it is the only way they can afford 
healthcare.
  I worked to make sure this bill bars insurance companies from 
charging women more just because they are women.
  I worked to make sure that this bill creates Collaborative Care 
Networks, to ensure that doctors, hospitals, and other health care 
providers work together to provide working families, lower income 
Americans, and those with chronic conditions the high quality 
coordinated care they need to stay healthy and out of emergency rooms.
  I worked to make sure this bill includes, among the choices it offers 
consumers, a public option that will focus on health care, not profits.
  I'm proud of my work on this bill, because it means American families 
and businesses will have the peace of mind that comes with knowing they 
can access affordable, quality care when they need it.
  It means that my son Joaquin can grow up in a country that is a 
little fairer, a little more humane, and a little more secure than the 
one I grew up in.
  I urge my colleagues on both sides of the aisle to vote for children 
and families by supporting this bill.
  Mr. KANJORSKI. Mr. Speaker, I rise today in support of H.R. 3962, the 
Affordable Health Care for America Act.
  The House has taken an important first step today to improve the 
affordability and accessibility of health care. While today's health 
care legislation is not perfect, action to address this important issue 
is absolutely necessary. If we do nothing to reform health care, health 
care costs are expected to double over the next ten years, just as they 
have over the last ten years.
  Insured Americans pay on average $500 per year just to administer 
health insurance, more than double the administrative costs paid in any 
other country which has a government-run health care system. The 
McKinsey Global Institute estimates that $91 billion a year is wasted 
on excessive insurance administrative costs.
  Because about 60 percent of all Americans under the age of 65 receive 
insurance through their employers, much of this waste is burdening 
American companies. American companies competing in the global economy 
cannot afford this economic disadvantage. The bill we voted on today 
attempts to reduce the costs of insurance to employers and employees by 
providing greater competition among insurers. According to a study by 
the Massachusetts Institute of Technology, a family of four would save 
$1,260 in annual health insurance premiums once this bill is enacted.
  It is estimated that 96 percent of all Americans will have access to 
affordable health insurance under this bill. While I believe that 
caring for our fellow citizens is a moral imperative, it also makes 
economic sense to have as many people covered by insurance as possible. 
Families USA estimates that every insured American family pays over 
$1000 per year in premiums just to cover the medical expenses of the 
uninsured, who obtain urgently needed health care through inefficient 
means such as visits to hospital emergency rooms. As we face the threat 
of pandemics such as the current swine flu, it is in the best interest 
of all of our health to make sure that sick people are treated quickly 
and affordably so that infectious diseases are not spread.
  While there are many detailed provisions in this complex legislation, 
it is important to note what the bill does not do. The only effect it 
will have on senior citizens who rely on Medicare is it will reduce 
their out-of-pocket costs for prescription drugs, as noted by AARP in 
its recent endorsement of the bill. The bill does not use tax dollars 
to pay for abortions. It does not require our smallest businesses to 
pay for insurance coverage for their employees. It will not result in 
the federal government controlling the delivery of health care; in 
fact, the non-partisan Congressional Budget Office (CBO) estimates that 
only six million Americans will choose to enroll in the government-
sponsored insurance plan, the so-called ``public option.'' It does not 
add to the federal deficit. CBO estimates that the bill will reduce the 
deficit by $109 billion over the first ten years.
  Finally, I want to praise the House leadership for including in this 
bill a provision which will help to fund the education of the next 
generation of doctors, some of whom I hope will be educated by our 
region's own medical college.
  We all share the goal of keeping American citizens healthy in the 
most humane and efficient means possible. I believe this bill is a 
reasonable first step toward reaching this goal.
  In closing, I appreciate the opportunity to share my thoughts about 
this important legislation.

[[Page 27511]]


  Mr. TIAHRT. Mr. Speaker, I rise in strong opposition to H.R. 3962. I 
cannot and will not support this government takeover of our health care 
system that will restrict choice, ration care, increase the cost of 
health care, greatly increase government spending, and lead to the 
destruction of the world's best medical care.
  Americans are fed up with Washington's out of control spending, with 
more and more power over their daily lives being put in the hands of 
nameless, unaccountable bureaucrats, and with the systematic shift of 
the United States Government from a government OF the people to a 
government FOR the people. The growing discontent began with the 
bloated stimulus bill that did nothing but grow a bigger Washington and 
create more bureaucratic jobs. It increased with the government 
takeover of General Motors, the cap and tax bill, the placement of 
power in the hands of unconfirmed and unconstitutional czars, and the 
grossly inflated spending bills passed for fiscal year 2010. With the 
Democrat attempt to takeover health care, the discontent has now come 
to a full boil.
  This spring, summer and fall the American people have spoken loudly 
and clearly about what they do and do not want in health care reform. 
The Democrats ignored these sentiments and introduced H.R. 3200 and the 
two Senate bills. This led to the most lively, spirited town halls in 
my 15 years in Congress, followed by an unprecedented number of phone 
calls, emails and letters sent to my office by concerned Kansans.
  The American people told us what they do and do not want: they do not 
want a government takeover of health care, the American people do not 
want higher taxes, the American people do very much want to keep their 
health insurance and increase their choices and access for those who do 
not have insurance.
  What was the Democrat response to their constituents? A new, bigger 
bill that again ignores the input of the American people and is even 
worse than H.R. 3200.
  The new bill is a government takeover of health care. H.R. 3962 is 
double the original H.R. 3200 at 1990 pages long and loaded with new 
mandates. The word ``shall'' appears 3,425 times--in other words--this 
is the government telling you to do something. The bill creates 118 new 
bureaucracies. The Congressional Budget Office (CBO) calculated the 
cost of the bill at $1.2 trillion but this does not include 28 
instances of hidden costs indicated by the ominous words indicating 
that certain programs be appropriated ``such sums as may be 
necessary.'' The bill raises taxes, on individuals and job creators, 
including a $461 billion surtax on small businesses according to the 
U.S. Chamber of Congress. The Pelosi bill will result in 5.5 million 
job losses at a time when unemployment is already over 10 percent. And 
to top all of that off--this bill completely rewrites 16th of our 
nation's economy.
  H.R. 3962 cuts benefits to seniors, does not ensure that Americans 
can keep their health insurance, limits choice, covers even more 
illegal immigrants than H.R. 3200 (2.5 million more according to CRS), 
and allows for taxpayer funded abortions.
  If H.R. 3962 is enacted into law, even the Democrats acknowledge that 
health care costs will increase. As PJ O'Rourke said, ``If you think 
health care is expensive now, wait until you see what it costs when 
it's free.''
  My biggest concern with the Democrat proposals is the intended 
rationing of health care. The Obama administration has already begun to 
set the framework for rationed care with comparative effectiveness 
research. This is a very dangerous road to travel down.
  In addition to all the other concerns I am also opposed to the Baucus 
and Pelosi attempt to destroy Health Savings Accounts (HSAs). HSAs are 
what we should be promoting as a way to expand choice, give patients 
more control over their medical spending, and reduce health care costs.
  I want health care reform and am saddened that this process has 
become so political that we won't see the much needed modernization 
that will ensure Americans have access to the best health care for 
decades to come. I am saddened that states like my home state of Kansas 
are forced to take drastic action to try to protect their citizens from 
being affected by Washington's takeover of health care.
  Republicans have offered better solutions and principles that should 
be included in any health care reform. Those principles should: let 
Americans who like their health coverage keep it, give all Americans 
the freedom to choose the health plan that best meets their needs; 
ensure that medical decisions are made by patients and their doctors, 
not government bureaucrats; and improve Americans' lives through 
effective prevention, wellness, and disease management programs, while 
developing new treatments and cures for life-threatening diseases.
  The Republican 219 page bill is a plan that will lower cost and 
improve health care access. This bill includes: tax incentives; 
Association Healthcare Options to let Americans group together for 
greater purchasing power; limitations on defensive medicine and 
implementing comprehensive medical liability reform; tackling waste, 
fraud and abuse (a $10 Billion annual cost to taxpayers generated from 
Medicare alone); and incentives for savings and increased use of 
personal Health Savings Accounts (HSAs). In addition, the Republican 
plan will ensure that Americans are not prevented from health coverage 
due to pre-existing conditions and are not subject to lifetime caps on 
treatment. Unlike the Pelosi and Obama plans, the Republican plan 
protects Medicare for seniors. Finally, the Republican plan protects 
taxpayers from funding abortions or health insurance for illegal 
immigrants. The Congressional Budget Office has confirmed that the 
Republican bill will lower premiums for the American people by up to 10 
percent. Under our plan, premiums for families and small businesses 
would be nearly $5,000 per year lower.
  I strongly encourage my colleagues to vote for the Republican 
substitute that will provide real solutions that will meet the needs of 
the American people. Our constituents have spoken loudly and clearly 
and it is our duty as their representatives to listen to them, not 
ignore them and use the sacred Speaker's gavel to impose personal 
political goals upon them.
  Mr. FILNER. Mr. Speaker, many Members of the House of Representatives 
have spoken at length on the ways that the Affordable Health Care for 
America Act will improve health care for all of our constituents. I 
wanted to draw attention to another significant benefit of this 
legislation: the creation of new high-paying jobs in this country. Let 
me repeat that for some of my friends on the other side of the aisle, 
this bill will create high-paying, high-quality jobs in healthcare 
delivery, technology and research in the United States.
  First, this bill will create enormous demand for healthcare workers, 
especially in the area of primary care. Insuring the millions of 
Americans in this country who currently have no insurance will allow 
them to see primary care providers and receive the wellness and 
preventive care they have been denied for too long. This influx of new 
patients will need doctors, nurses and technicians for their care, 
while reducing overall healthcare costs because they will not need much 
more expensive hospitalizations. I support channeling resources that 
for too long have been used to treat people once they become sick into 
jobs and services that will prevent people from getting sick in the 
first place.
  Second, this bill will continue the efforts we began in the stimulus 
package to deploy new health information technologies that better 
manage both the quality of care people receive and the cost at which 
they receive it. New health care exchanges and new demands on the 
health system to provide high-quality and cost-effective health care 
will create new opportunities and markets for our brightest technology 
minds. They will be incentivized to create and develop products that 
will be a win/win for Americans: high quality health care at an 
affordable price.
  Third, this bill will create high quality research opportunities in 
this country. The Energy and Commerce Committee enacted a framework for 
allowing biosimilar competition in this country. This new class of 
medicines will help lower costs and bring competition to one area that 
is key to the future of our healthcare system. Biotechnology is on the 
cutting edge of efforts to reducing costly invasive procedures and 
allowing our constituents to live healthier and more productive lives. 
The creation of this new class of medicines comes with requirements for 
new clinical research and testing, especially in the area of whether a 
new biosimilar can be interchangeable with an innovator's product. This 
research will create high quality and high paying jobs and it is 
imperative that we keep this research and these jobs in this country. 
We cannot allow these research opportunities to leave this country, and 
I intend to work with the Secretary of HHS and the Commissioner of the 
FDA to ensure they stay in the United States.
  Mr. Speaker, I do not look at this bill as one of cost or drain on 
the economy of our country like so many of its opponents on the other 
side of the aisle. I see this bill as an exciting opportunity to create 
the kind of jobs we so desperately need in this country while at the 
same time improving the lives of ALL Americans. This bill will improve 
health care, create jobs and grow our economy.
  Mr. COSTELLO. Mr. Speaker, today is a historic day in the House of 
Representatives, and will be one of a handful of votes that can be 
deemed the most important of our careers.

[[Page 27512]]

We are considering today how to improve the provision of health care in 
America. Spiraling costs, insurance limitations and a lack of insurance 
coverage continue to impact families, our economy, and ultimately our 
way of life. It is for this reason that after careful consideration, I 
will vote in favor of H.R. 3962.
  As the health care debate has developed this year, I have held 
meetings with individuals, families, health care providers, business 
owners and other groups. What everyone can agree on is that our health 
care system is broken and needs attention. At the simplest level, we 
need to put an emphasis on preventive medicine. As the old saying goes, 
an ounce of prevention is worth a pound of cure. We treat too many 
people in emergency rooms instead of doctors' offices, and often when 
they are sickest and care is the most expensive. H.R. 3962 moves us 
toward preventive care in a variety of ways, but chiefly through 
providing health insurance to 36 million more Americans. Having 
insurance will allow them to see a doctor on a regular basis and detect 
health problems earlier.
  Most importantly today, passing H.R. 3962 keeps the process of health 
care reform moving forward. Today is a very important step, but there 
is still a long way to go. As we all know, the Senate is working on its 
version of health care reform legislation, and that bill is likely to 
be very different from this one, but I am confident we can craft a 
final product that incorporates these goals and makes our health care 
system better.
  Mr. Speaker, I am glad that we slowed our process down and took some 
additional time before bringing it the floor. This is not a perfect 
bill, but I think it will make a positive difference for the entire 
country. Over 300 organizations have endorsed it, including AARP, the 
American Heart Association and the American Medical Association. I urge 
my colleagues to vote for H.R. 3962, and keep us moving toward a 
healthier America.
  Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I strongly support 
H.R. 3962, the Affordable Health Care for America Act, which delivers 
on a promise Americans have been waiting for since the New Deal, a 
promise that families can get the health care they need, when they need 
it, without facing economic ruin.
  I have previously spoken about the ways that this bill will help 
ensure access to affordable, high quality health care for American 
families. But another significant benefit of this legislation which has 
not received much attention is its promotion of high-paying research, 
high tech, and manufacturing jobs.
  Contrary to the claims that this is a ``job killing bill,'' in fact, 
this bill will create thousands of jobs here in the United States.
  First, this bill will increase demand for healthcare workers, 
including doctors, nurses, nurse practitioners, physician assistants, 
home health workers, and more. More affordable insurance means more 
families getting the primary and chronic care they need instead of 
waiting until they need an emergency room. And it means more middle 
class American jobs that can't be exported.
  Second, this bill will continue the investments begun in the American 
Recovery and Reinvestment Act, also known as the stimulus bill, to 
expand the use of health information technology.
  Health IT will help better manage the quality and cost of care 
patients receive by eliminating duplicative tests and ensuring that 
patients don't receive the wrong medicine or the wrong dose. And 
investment in health IT creates jobs--jobs in hardware production, 
software design, and computer training. When we invest in quality 
health care for all Americans, we are investing in jobs.
  Finally, this bill will promote more of what America already does so 
well: medical research. By allowing more Americans access to health 
insurance, this bill will increase the demand for advanced medical 
technologies that are manufactured right here in America.
  And by creating a process for the Food and Drug Administration to 
approve so-called ``biosimilar'' drugs, this bill will encourage 
competition in the cutting edge field of biologic drugs.
  This new class of medicines will help cure and treat more Americans 
at lower costs. And the promise of protection for intellectual property 
and an FDA structure to approve bio-similars will result in increased 
investment in this industry, which already provides thousands of well-
paying jobs in California and across the country.
  I hope to work with the Secretary of Health and Human Services, the 
Commissioner of the FDA, and like-minded colleagues in Congress to 
ensure that these important research and manufacturing jobs stay right 
here in the United States.
  In sum, this bill preserves and promotes the strength of the American 
health care system: innovation. And it fixes the shortcomings: spending 
too much while caring for too few.
  If we fail to pass this bill, we fail American families, and we fail 
the American economy. As a champion of both, I strongly support this 
bill.
  Mr. ALEXANDER. Mr. Speaker, after months of meeting with constituents 
and business leaders, as well as hosting town halls and roundtable 
discussions, I can say that American public has clearly stated their 
opposition to this government takeover of health care.
  H.R. 3962, the Affordable Health Care for America Act, states in 
section one that this legislation ``builds on what works in today's 
health care system, while repairing what's broken.'' I agree that 
improvements need to be made to drive down medical costs, but placing 
individuals under one bureaucrat-run umbrella does not build on what 
works or make any repairs. The bill includes the government-run public 
option, cuts Medicare and Medicare Advantage programs, and raises taxes 
on middle class families. In addition, the bill does not protect the 
interests of small businesses nor does it adequately address defensive 
medicine. And, in the midst of states struggling with fiscal 
constraints, it will burden them with more unfunded mandates from the 
federal government.
  In the President's address to Congress on Sept. 9, President Obama 
said, ``Nothing in our plan requires you to change what you have.'' A 
study by the Lewin Group shows that two out of every three people would 
lose their current coverage, including up to 114 million people who 
receive health benefits through their employer or other current 
coverage if a government-run plan ``competes'' with private companies. 
I don't see the choice in this.
  Medicare cuts total $162 billion. As a result, Medicare Advantage 
plans will drop out of the program, limiting seniors' choices and 
causing many to lose their current health care coverage. Medicare 
Advantage has been successful in providing seniors with choice, 
selection and value. This is especially true for residents of rural 
America, where seniors have previously not had sufficient private 
alternatives. Currently, over 600,000 seniors are Medicare 
beneficiaries in Louisiana, while over 10,694 seniors in the 5th 
District are enrolled in the Medicare Advantage program.
  The bill includes taxes on individuals who do not purchase 
government-forced health insurance. It also imposes new taxes on 
businesses who cannot afford to fund government-forced health coverage 
for their workers, therefore violating the bill's new employer mandate 
and triggering an additional 8 percent payroll tax.
  The bill also prohibits the reimbursement of over-the-counter 
pharmaceuticals from Health Savings Accounts (HSAs), Medical Savings 
Accounts, Flexible Spending Arrangements (FSAs), and Health 
Reimbursement Arrangements (HRAs), increases the penalties for non-
qualified HSA withdrawals from 10 percent to 20 percent, and places a 
cap on FSA contributions. Because at least 8 million individuals hold 
insurance policies eligible for HSAs, and millions more participate in 
FSAs, all these individuals would not be able to keep the coverage they 
have without facing tax increases.
  The grand total amount of tax increases included in this legislation 
equals approximately $729.5 billion over ten years. Imposing these new 
tax increases in the middle of a recession--with unemployment numbers 
we haven't seen since 1983--will only harm the economy and kill jobs.
  This bill intends to ensure that generic biologic companies will have 
to do some research and clinical trials before the FDA will approve 
them for use in the United States. This dramatically increases patient 
safety as generics come to market. Likewise, keeping research and 
trials in the country means more jobs at home. I hope this is included 
in discussions as the health care debate continues in the coming 
months.
  The CBO has also said that this bill will increase seniors' Medicare 
prescription drug premiums by 20 percent over the next decade. While 
the cost of living continues to rise during these tough economic times, 
I know that many cannot afford this increase. Medicare finances are 
rapidly deteriorating and we should be working on real solutions that 
ensure the long-term financial stability of Medicare.
  Choice is not option in this government takeover of our health care 
system. I am genuinely concerned for the well-being and options that 
the people of this great nation have. I do not believe H.R. 3962 best 
represents what the American people are asking for.
  I agree that improvements need to be made to our system currently in 
place. However, a solution should be built upon the principle that when 
individuals--not the government, insurance companies, or employers--are 
given

[[Page 27513]]

control and ownership, we will achieve full access to coverage and see 
the entire system move in a more positive, patient-centered direction. 
America needs economic relief in the form of tax breaks for working 
families and small businesses, and fiscal discipline in Washington. 
Instead, our federal government keeps pushing policies that will impose 
harmful taxes and increase our national debt, saddling Americans who 
are already hurting with even more financial burdens. We must work to 
find real solutions that will help create jobs and lower health care 
costs.
  Everyone can agree that affordability, accessibility, portability, 
and quality should be the outcome of any overhaul of the health care 
delivery system. More specifically, it should be guaranteed that 
medical decisions are kept in the hands of patients and their doctors; 
the cost of insurance is lowered, and in turn the number of Americans 
who have insurance is increased. The American people deserve a plan 
that allows them to keep their health care coverage if they like it, 
and have the freedom to choose the plan that best meets their needs. As 
I have said before, and as I will say again, I will not support any 
type of health reform plan that raises taxes, rations health care, 
eliminates employer-sponsored health benefits for working families, or 
allows government bureaucrats to make decisions that should be made by 
families and their doctors.
  Mr. VISCLOSKY. Mr. Speaker, I am proud to support the Affordable 
Health Care for America Act, a bill that will significantly improve our 
healthcare system.
  For too long, our healthcare system has allowed millions of Americans 
to go uninsured, tolerated egregious and abusive business practices by 
big insurance and pharmaceutical companies, and ignored skyrocketing 
costs. It has diminished our nation's collective health and drained our 
economy. The Affordable Health Care for America Act represents a 
significant effort to address the iniquities of our current healthcare 
system.
  Specifically, the Affordable Health Care for America Act strengthens 
the healthcare market for all Americans. For those with insurance, the 
measure would establish benefits to be included in all health insurance 
options, including preventative care, mental health services, and 
dental and vision services for children. Additionally, the measure 
would establish annual and lifetime out-of-pocket spending caps to 
ensure that no family faces bankruptcy due to medical expenses. And the 
Affordable Health Care for America Act would eliminate the decades-long 
exemption of health insurance companies from federal anti-trust laws, 
enabling the regulation of abusive business practices.
  For those without insurance, the Affordable Health Care for America 
Act would establish a public health insurance option to compete with--
not replace--private insurance plans. The public health insurance 
option would aim to provide more Americans with healthcare coverage and 
would be financed through its premiums. The measure would allow the 
Secretary of Health and Human Services to negotiate physician and 
hospital rates for the public option and would prohibit insurance 
companies from denying coverage based on a pre-existing condition.
  Importantly, the measure would repeal the prohibition on negotiating 
with pharmaceutical companies and would require the Secretary of Health 
and Human Services to negotiate the prices of prescription medications 
for Medicare beneficiaries. It is my sincere hope that these 
negotiations will ameliorate the high out-of-pocket costs for 
prescription medications faced by our seniors. Additionally, the 
Affordable Health Care for America Act would provide savings to the 
Medicare programs by improving payment accuracy to Medicare Advantage.
  The Affordable Health Care for America Act would reduce the costs to 
small businesses, America's economic engine, by establishing a Health 
Insurance Exchange where these businesses will benefit from large group 
rates and a greater choice of insurance options for their employees. 
Further, the measure would provide tax credits to eligible small 
businesses for assistance with the costs of providing health insurance 
to their employees.
  Finally, the Affordable Health Care for America Act is not only fully 
paid for, but according to the non-partisan Congressional Budget Office 
it would reduce the deficit by $104 billion over the next ten years and 
would continue to reduce the deficit in the following decade.
  Through these provisions and others I believe that the Affordable 
Health Care for America Act will accomplish my goals for healthcare 
reform, namely to give more security and stability to those who have 
health insurance, to provide affordable, quality options to those who 
do not have health insurance, and to lower the cost of healthcare for 
families, businesses, and society.
   Although this bill may not be perfect, it will improve our 
healthcare system. It is the result of a lengthy, transparent process 
that has helped the bill evolve and improve at each step of the way. I 
will continue to closely monitor the legislation's progress.
   Voting for comprehensive healthcare reform at long last was a 
gratifying experience. I believe that a generation from now people will 
ask the question, what took us so long?
  Mr. REYES. Mr. Speaker, this is a momentous occasion for the American 
people, particularly for the hundreds of thousands of El Pasoans who 
have unjustly struggled without health insurance in the world's 
wealthiest nation. The Affordable Health Care for America Act, as 
passed by the House, will dramatically improve the quality of life for 
so many families in our community, who will finally have access to 
quality affordable health coverage.
  I am particularly pleased this legislation incorporates a provision 
that I, along with Majority Leader Steny Hoyer, and others worked to 
include that will support the development of our medical school. The 
measure will allocate $100 million each year through fiscal year 2015 
to the Department of Health and Human Services to help develop medical 
schools in federally-designated health professional shortage areas for 
construction, equipment, curriculum and faculty development. This is an 
exciting opportunity for our community.
  The House passage of the Affordable Health Care for America Act is 
one of the most significant legislative victories for the people of El 
Paso. Our community has one of the highest concentrations of America's 
uninsured population, with over 230,000 residents without health 
coverage, one in three people. Texas has the highest rate of children 
and adults without health insurance in the entire nation. The status 
quo is unacceptable, and we can no longer afford to pass this growing 
problem to future generations.
  While our community is spending a greater share of property taxes to 
pay for individuals without health coverage, insurance companies have 
continued to engage in practices that protect their bottom lines. For 
too long, insurers have been the gatekeepers to our health care system, 
with the power to dictate who receives health coverage and who does 
not. Americans with pre-existing conditions and serious illnesses are 
too often denied coverage or are dropped from their existing insurance 
plans for developing a serious illness or reaching their cap on 
coverage, and are denied access to the medical care they need.
  When people lack access to quality affordable preventative care, they 
end up in our emergency rooms for ailments that could have been treated 
by a family doctor or seek treatment for conditions that should have 
been diagnosed earlier. When these patients fail to pay their medical 
bills from publically-financed hospitals such as University Medical 
Center, local property taxes are used to cover these expenses. Since 
1998, El Paso property tax payers have spent over $400 million to pay 
for treatment and services for those patients who could not afford to 
pay their medical bills.
  The Affordable Health Care for America Act will dramatically reduce 
the number of people without insurance in El Paso. First, it prohibits 
insurance companies from denying coverage due to ``pre-existing 
conditions.'' It requires that every American obtain health coverage, 
and provides ``affordability credits'' to individuals and families with 
incomes up to 400 percent of the federal poverty level (currently 
$43,430 for individuals and $88,200 for a family of four).
  The legislation also requires that most employers provide coverage. 
It includes exemptions for small businesses with payrolls of less than 
$500,000 and offers generous tax credits for those small businesses 
that elect to provide coverage for their employees. The bill creates an 
``insurance exchange,'' that will offer affordable health insurance 
plans for individuals without employer-provided or government-provided 
insurance (such as Medicaid and Medicare). This exchange will include a 
public option to encourage competition with private insurers to keep 
prices low for consumers.
  This bill also brings much needed relief and peace of mind for those 
who do have insurance coverage, as all Americans will no longer have to 
worry about the possibility of financial ruin due to a serious illness. 
It caps annual out-of-pocket expenses at $10,000 for families and 
$5,000 for individuals, and prohibits insurance companies from imposing 
lifetime limits on an individual's coverage.
  Our local community leaders have expressed their support for health 
insurance reform, and both the city and the county have passed 
unanimous resolutions in support of reform. The Affordable Health Care 
for America Act is endorsed by over 300 national organizations and 
associations, including the

[[Page 27514]]

AARP, the American Medical Association, the American Cancer Society, 
the American Heart Association, and many other medical professional 
organizations.
  The passage of this landmark legislation by the House of 
Representatives is an historic achievement and reflects the commitment 
and determined leadership of President Obama and the Democratic 
Congress to follow through on a key promise to help middle class 
families, who have endured years of rising medical costs. I commend my 
colleagues for their determination to pass this truly historic 
legislation that will lower health care costs for all Americans, and 
strengthen our country's financial future.
  Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I rise today to 
oppose language in the Republican substitute that threatens the well-
being of patients in hospitals across the country.
  The goal of the underlying legislation is to provide affordable, 
quality healthcare to every American. According to The Institute of 
Medicine, nearly 100,000 people die every year because of medical 
errors in America's hospitals. I cannot understand how reducing the 
accountability of our healthcare practitioners would lower that number 
or improve the quality of healthcare in this country.
  The facts are clear. Those states that restrict damage awards and 
limit access to courts for patients injured by negligent doctors have 
seen limited or no reduction in healthcare costs. Instead, many have 
seen an increase in the cost of malpractice insurance. In fact, for 
every malpractice damage award, 3 to 7 people die due to medical 
errors.
  While we all share a goal that doctors practice medicine with 
confidence and avoid needless tests, we should not limit access to 
justice where reckless action permanently alters the lives of patients 
and their families. Make no mistake, that's what the Republican 
substitute would do.
  If we want to lower healthcare costs, let us instead cut down on 
medical error by encouraging adoption of best practices, standardizing 
safety procedures that are proven to reduce infection, and lowering 
malpractice premiums by creating more competition in the insurance 
industry. I listened to the Americans who visited Washington this week. 
Many spoke about a fear of monopolies and in favor of increased 
competition. I agree. Let's make the insurance companies comply with 
antitrust laws and operate on the same competitive playing field as 
other American businesses.
  One of the great guarantees the founders provided in our Constitution 
was the ability to address grievances in a court of law. Our courts 
remain a great equalizer that allows every American the opportunity to 
seek justice when wronged. Limiting this guarantee goes against that 
spirit and leaves grieving and injured families without access to 
justice. I ask my colleagues to join me in opposing this substitute.
  Ms. CORRINE BROWN of Florida. Mr. Speaker, tonight, I'm thinking 
about my grandmother, and all the grandmothers out there--back in 
November of 2003 when the Republicans passed their Medicare 
Prescription Drug bill, they put a provision in there known as the 
donut hole. And that's why I voted against that bill because I knew 
that my Grandma needed her prescriptions yet couldn't afford them 
because of this gap in coverage. And they made it illegal for the 
Secretary of HHS to negotiate the prices of drugs, even though we in 
Congress allow the VA and DOD to negotiate drug prices.
  Yet this bill closes that prescription drug loophole. It makes it 
impossible for insurance companies to deny people health care because 
of a pre-existing condition, and it allows the Secretary of HHS to 
negotiate drug prices, which WILL help to bring down cost.
  Secondly, one of the most family friendly provisions in this bill: 
families can keep their children on their health care insurance policy 
until age 27! This will be a great assistance to young adults studying 
in graduate school, or those just starting out in their career and 
barely making enough to get by.
  To whom God has given much, much is expected. I strongly urge my 
colleagues to vote in favor of this bill to reform health care in our 
country and make sure access to health care is a right for every 
American, not a privilege.
  Mr. ETHERIDGE. Mr. Speaker, I rise today in support of H.R. 3962, the 
Affordable Health Care for America Act. This bill is essential to 
improving North Carolina's economy and will lower health care costs for 
millions of Americans. I am committed to enacting comprehensive health 
care reform that contains costs, protects patient choice, and assures 
quality, affordable care for all Americans. As the only North Carolina 
Member on the House Ways and Means Committee, a Member of the Budget 
Committee, and a supporter of fiscal responsibility, I am pleased that 
this legislation is fully paid for and according to the Congressional 
Budget Office will reduce the deficit both in the short and long term.
  Working families and small businesses are facing crushing health care 
costs that threaten their lives and livelihoods. Health care costs will 
reach $2.5 trillion in 2009, more than we are expected to spend on the 
wars in Iraq and Afghanistan this decade. Families already have 
experienced health care costs doubling in the past 10 years. Without 
reform, health care costs will skyrocket in the next decade. 
Independent analysis has predicted that family premiums will be $1,000 
to $9,000 lower in 2016 under this legislation compared to what they 
would be without reform.
  H.R. 3962 will improve health care for seniors in Medicare by 
reducing costs and extending Medicare's solvency. This bill brings an 
end to the prescription drug ``donut hole'' which has unfairly burdened 
the pocketbooks of seniors, decreasing out-of-pocket costs by $500 
immediately, cutting copayments in half in the short term, and fully 
closing it over the next 10 years. H.R. 3962 also provides better and 
more timely payments to doctors who accept Medicare and attacks waste, 
fraud and abuse in Medicare ensuring more money goes to benefits and 
improving senior health and quality of life.
  Too many people have their choices limited by insurance companies and 
financial decisions, rather than by patients and doctors. H.R. 3962 
will expand individual choice and prevent insurers from denying 
benefits that doctors recommend. This bill will place caps on out-of-
pocket health expenses, and remove the ability of insurance companies 
to place annual or lifetime limits on coverage. Choice will be 
reinforced with one-stop comparison insurance shopping through a health 
insurance exchange.
  During this economic downturn, H.R. 3962 will help small businesses 
address the crushing costs of health care. In particular, this 
legislation will curb skyrocketing health care costs and provides 
greater access to health care for small businesses. Companies that 
offer their employees health insurance coverage will get a tax credit 
for two years to help them transition to, or continue, providing health 
benefits to their employees--paying up to 50 percent of their costs.
  Mr. Speaker, as this bill moves to the Senate and then to conference, 
I am hopeful that we can make sure that H.R. 3962 does not 
unintentionally burden small businesses who employ seasonal workers. 
While tax incentives in the bill are designed to help small employers 
cover health care expenses, there are no allowances for seasonal 
workers common to the agricultural industry. Workers who are only 
employed for a short time by an employer should be able to get health 
insurance, but there must be provisions to ensure that this is 
affordable and not burdensome to their temporary employer. As we work 
through the process of passing a final bill to be sent to the 
President, I hope leadership will work with me to resolve this issue.
  H.R. 3962 is fiscally responsible and will improve the health and 
health care of people across my district, North Carolina, and the 
country. I am pleased to be able to vote in favor of this historic 
legislation.
  Ms. FOXX. Mr. Speaker, small business owners and employees need more 
choices of health insurance plans, not fewer. This bill will drive out 
the private health insurance market and permit the government to 
determine if the health insurance options a small business offers are 
``acceptable.''
  The bill places a new tax-compliance paperwork burden on all small 
business owners.
  This bill will kill jobs. It does nothing to lower the cost or 
increase choice in the marketplace for America's small business. It 
will harm small business owners with costly employer mandates and 
punitive payroll taxes.
  The Joint Committee on Taxation and the NFIB agree that more than 
one-third of the $460.5 billion raised by this bill's surtax will come 
from small business income.
  Small business owners have shared their concerns about H.R. 3962 with 
me. One small business owner in Statesville N.C. summed it up:
  ``If this bill is passed the way it is written, my business will be 
unable to afford to comply with the legislation. My business has 
drastically cut expenses, delayed capital investments and decreased our 
work force to stay competitive. If H.R. 3962 is passed by Congress it 
will force us to close down our business and end the paychecks for the 
56 employees who depend on our company to feed their families.''
  Mr. LUJAN. Mr. Speaker, as I came to the floor tonight I was reminded 
of a constituent, Aunt Adrian, who we lost to cancer this last year and 
who couldn't afford insurance, she spent her last few months worrying 
about bills,

[[Page 27515]]

rather than getter better. This story didn't have to end this way.
  We reached this point today because people have had enough.
  People who have been ignored and shunned, because they are sick;
  People who have lost their homes and all they have because a health 
insurance company slammed a door on them and denied them coverage they 
thought they had.
  People who deserve to be treated fairly and with dignity.
  We are here today not to frighten and scare the American people with 
things that are untrue
  But to act, to make a difference, to have the courage and will to put 
the people first.
  And I now know that we do have the courage and the will to get this 
done, Aunt Adrian and the American people deserve no less.
  Ms. RICHARDSON. Mr. Speaker, I rise today in strong support of H.R. 
3962, the Affordable Health Care for America Act of 2009, because this 
bill is good for seniors, good for women, good for small businesses, 
and good for all Americans.
  I would like to thank Speaker Pelosi, House Majority Leader Hoyer, 
Congressman Dingell, Congressman Rangel, and Congressman Waxman for 
their skill and leadership in bringing this historic bill to the floor. 
I would also like to thank my colleagues who have worked so hard to 
bring about a workable solution to one of the most critical challenges 
in the history of our nation.
  President Theodore Roosevelt proposed national health insurance in 
1908 because he could not stand by and watch American families go 
bankrupt when their children fell ill. Forty years later in 1948, 
President Truman proposed it again. Under the leadership of Lyndon B. 
Johnson and a Democratic Congress, Medicare was enacted in 1965 which 
provided health care for senior citizens. Thirty years later, Congress 
passed the State Children' Health Insurance Plan which expanded 
affordable coverage to millions of poor children.
  Today, this seventh day of November in the year 2009, we write 
another great chapter in the remarkable history of this country. Today, 
we extend to tens of millions of our fellow citizens the security that 
comes from knowing that they will have health care that is there when 
they need it and won't bankrupt their families. Today, we keep faith 
with those who came before us and those who will come after us. Today, 
we will pass the Affordable Health Care for Americans Act of 2009 and 
change America for the better.
  The health care system we have now is not working for middle and 
working class families, not working for businesses trying to compete in 
a global economy, not working for taxpayers or for the uninsured. There 
are 54 million Americans who are uninsured who need us to reform this 
broken system. 1 in 5 Californians are uninsured or underinsured. These 
numbers are staggering and if we do nothing, they will only grow worse.
  Mr. Speaker, House Republicans have offered a bill that they claim 
solves the broken health care system, but the reality is quite 
different from what their rhetoric makes it out to be. The fact is the 
Republican substitute leaves affordable health insurance out of reach 
for millions of Americans. It will allow discrimination based on 
gender, age, and preexisting conditions to prevail in the insurance 
industry. It will do nothing to protect consumers. It is not the 
answer.
  Mr. Speaker, the Affordable Health Care for Americans Act is a better 
bill. It is the answer to the broken health care system. This bill 
provides American families with stability and peace of mind. Never 
again will they have to choose between their health and their 
livelihood. This bill provides American families with higher quality 
health care. It leaves important health decisions up to patients and 
doctors, not to insurance companies. This bill provides American 
families with greater choice. It creates a high-quality, robust, public 
health insurance option for families to choose from. Finally, this bill 
lowers costs for American families. It eliminates co-pays and 
deductibles for preventive care while putting an annual cap on out-of-
pocket expenses for American families.
  Mr. Speaker, this bill is the answer to the problems faced by real 
American families today. The Republican bill is fantasy. It is not 
grounded in reality. Now, we need to stop playing politics and focus on 
actually improving people's lives. H.R. 3962 will reform the health 
care system so that it provides quality, affordable coverage that 
cannot be taken away. This bill eliminates discrimination based on 
gender and pre-existing condition. It eliminates the prescription drug 
donut hole for seniors. It ends the era of no and begins the era of yes 
for millions of Americans seeking coverage.
  As FDR once said, the test of our progress is not whether we add more 
to the abundance of those who have much, it is whether we provide 
enough for those who have little. It is time for us to move forward. It 
is time for us to take this great nation in a new direction. It is time 
for us to look out for all Americans in their time of sickness and 
need. The hour is late, and the need is great. I urge my colleagues to 
vote ``aye'' on H.R. 3962.
  Mr. SHULER. Mr. Speaker, as you know I am opposed to the bill we are 
considering today for many reasons that I have articulated previously. 
I am pleased, however, that the bill strikes the appropriate balance on 
the issue of follow on biologics. This bipartisan compromise language 
will provide lower cost options to consumers and my constituents 
without destroying a healthy and functioning bio-tech industry in this 
country. The Barton-Eshoo biosimilar amendment in the Energy and 
Commerce Committee was one of the few issues that was addressed on a 
truly bi-partisan basis and ought to serve as model on how things 
should get done in Congress.
  I believe it is critical that the creation of a pathway for new 
products does not destroy the ability or the incentives of innovator 
companies to develop breakthrough technologies. We have a moral 
obligation to provide a safe and effective pathway of bringing 
competition that will benefit patients. I wish we could consider this 
as a stand-alone bill because it would pass with the kind of 
overwhelming bi-partisan support that Americans across the country wish 
to see.
  However, these provisions are only the first step in a long path to 
the marketing of these new products. New research and clinical testing 
will have to occur and the FDA will write rules that will ensure this 
research is done safely and effectively. One of the reasons I have long 
supported the U.S. biotechnology industry is that it is a homegrown 
success story that has been an engine of job creation in this country 
and in my home state of North Carolina. Unfortunately, many of the 
largest companies that would seek to enter the biosimilar market have 
made their money by outsourcing their research to foreign countries 
that don't have the same safety and efficacy standards that we have in 
the United States. With this week's devastating news that unemployment 
has reached 10.2 percent it is critical that we preserve jobs in 
America. While the innovators have created jobs here, these generic 
companies have shipped them overseas, so they can turn around and sell 
cheap knockoffs of innovative American products.
  As this new market launches in the U.S., we need to ensure that we 
foster innovative products in this country for the creation of jobs and 
research that will go into proving whether these products are 
interchangeable with the innovator's products. I don't know whether 
these companies can create such interchangeable products, but I am 
certain that the research and testing of whether or not they should 
occur in this country and not somewhere across the globe. Testing and 
research on these interchangeable biosimilars should be required to 
occur in this country to ensure that it is done properly and safely.
  Mr. BOOZMAN. Mr. Speaker, the Pelosi Health Care Bill is a bad bill 
disguised as health care reform. I have heard my constituents and the 
American people and they say they don't want this government takeover. 
They want the right to make their own health care choices. I agree that 
we need health care reform because the costs are too high. There is 
nothing more frustrating as a medical professional then when my 
patients can't afford the prescriptions I write for them. The Majority 
plan will put Washington between me and my patients and this is 
unacceptable.
  We all deserve access to quality and affordable health care. 
Unfortunately, a public option doesn't guarantee that we will 
accomplish this. This government takeover will increase taxes, take 
away health care choices Americans deserve to make and create more 
bureaucratic red tape. We don't want reforms that come with higher 
costs while the quality and access to health care suffers.
  The cost is a staggering $1.2 trillion and to think that won't impact 
our national deficit and state budgets is unrealistic. The increased 
price for greatly expanding Medicaid will be an unfunded mandate to 
Arkansas taxpayers that at the bare minimum will cost $205 million and 
could be as high as $596 million. This is an unfunded mandate that we 
cannot force Arkansans to pay. Health reform should not end up costing 
hardworking Americans. Our citizens deserve better
  Mr. ISSA. Mr. Speaker, today I will vote in strong opposition to H.R. 
3962, the ``Affordable Health Care for America Act.''
  This government takeover of health care is filled with tax increases, 
job killing mandates, Medicare cuts, bureaucrat additions, and 
entitlement expansions. This bill will lead to higher

[[Page 27516]]

health care premiums and a growth in long-term health care costs.
  Despite this bill's many faults, I support the bill's language 
establishing a market for biosimilars which balances the desire to 
provide cheaper biologics with the need to continue incentivizing 
investment in research and development. The bipartisan language 
approved by the House Energy and Commerce Committee earlier this year 
would create an FDA approval process that allows for the continued 
development of biosimilar products.
  This language appropriately protects intellectual property rights by 
encouraging the creation of new technologies and helps protect patients 
from possibly dangerous, insufficiently tested biosimilars. Because 
biologics are more complex and susceptible to change during 
formulation, it is of the utmost importance that we only support a 
process that provides for a safe biosimilar market.
  It is critical at this time of 10.2 percent nationwide unemployment 
that the federal government allow job creating industries, like 
biotechnology, to continue to invest and create jobs. It is unfortunate 
that the Majority wrapped up a good biosimilar bill in a bad health 
care bill, but I hope that we have the opportunity to support the 
Eshoo-Inslee-Barton biosimilar provisions in a separate legislative 
vote.
  Mr. McCARTHY of California. Mr. Speaker, I rise today to express my 
strong opposition to H.R. 3962. Specifically, I am very concerned about 
how the House Democratic Leadership's government takeover of health 
care legislation will affect the biotech industry, which has been a 
source of innovation and job creation in California.
  Californians know very well how the burden of heavy taxes and 
regulations can harm small businesses and innovation, as our state 
economy continues to lag and continues to have an unemployment rate 
much higher than the national average. On top of state taxes and 
regulatory burdens, H.R. 3962 would only add on to the devastating 
burdens facing our biotech industry, through its $20 billion excise tax 
on medical devices and by establishing a pathway for follow-on 
biologics that could harm innovation and American jobs.
  As one of the biotech leaders in our country, California boasts more 
than 2,000 biomedical companies and has created more than 271,000 jobs. 
The proposed excise tax, whose purpose seems to be solely to raise 
revenue, is a job killer and would stifle innovation. It will 
ultimately result in making it more difficult for millions of Americans 
to have access to life-saving medical devices that they need for their 
health and well-being.
  Further, H.R. 3962 would establish a new pathway for follow-on 
biologics that could slow advances to new life-saving therapies, and 
ultimately reduce the number of American jobs. The bill does not 
expressly require clinical trials for follow-on biologics to be 
completed in the United States, which could allow for these studies to 
be conducted overseas. Over the past decades, many innovator biologics 
have demonstrated to be safe, reliable and life-changing--the product 
of strong clinical trials and research done by dedicated researchers 
here in America. As unemployment has now crossed 10 percent nationally, 
and is over 12 percent in California, I hope that we could continue to 
foster the creation of jobs and research in America.
  These are some of the many concerns I have with H.R. 3962, which is 
why I instead support the Republican health care alternative. The 
alternative excludes the unnecessary and burdensome excise tax in H.R. 
3962, and also includes a responsible pathway for follow-on biologics 
by including provisions from the Pathways for Biosimilars Act, which I 
am a proud cosponsor of. By passing the Republican alternative, we can 
ensure that the American biotech industry can continue to lead the 
world in innovative therapies and that the necessary research and 
clinical testing in the field can continue to be done domestically so 
we can continue to create good-paying American jobs.
  Californians, and all Americans, need Washington to pass strong 
common-sense health care solutions. But we need solutions that strike a 
balance in reducing health care costs, strengthening health care 
access, and allowing health innovators, like our biotech industry, to 
continue to research and improve therapies for patients. That is why I 
support the Republican health care alternative--it addresses the needs 
of patients and ensures that we keep good-paying jobs in America.
  Mr. BONNER. Mr. Speaker, I rise today to state my objection--in the 
strongest way I know how--to Speaker Pelosi's health care bill.
  This bill represents everything I have fought against during my years 
in public service . . . it raises taxes by hundreds of billions of 
dollars, it hides deficit spending with dubious accounting gimmicks, 
and it will vastly expand the federal government's scope and size in 
every aspect of our daily lives and take even greater control over one 
sixth of our nation's economy.
  Among other things, this bill piles crushing mandates on small 
businesses, it wrings hundreds of billions of Medicare dollars out of 
our doctors, hospitals, and other providers. It decimates the popular 
Medicare Advantage program, which millions of seniors depend on. 
Moreover, it will be the mother of all unfunded mandates on state 
budgets which--like my home state of Alabama--are already stretched 
thin because unlike the federal government, most states actually 
balance their budgets.
  Mr. Speaker, over the past several months I have heard from thousands 
of Alabamans who have called, written, and e-mailed my office. In 
August, my staff and I held 19 town meetings throughout Alabama's First 
District where more than 5,000 people came out to voice their 
opposition to this massive takeover of our health care system.
  My friends and colleagues, the vast majority of the people I work 
for--and have heard from--are unambiguous--they do not want this bill.
  In fact, most Alabamians--and, I believe, most Americans--want to 
preserve what's best about our health care while lowering costs and 
improving access. That's why I will not only be opposing H.R. 3962, but 
I am proud to support the Republican substitute. My Republican 
colleagues and I believe this bill would lower costs in both the short 
term and the long term, honoring our pledge for fiscal responsibility 
while broadening access to quality heath care through lower costs and 
more competition.
  Mr. Speaker, I only have one vote but I will cast that vote against 
this legislation that The Wall Street Journal correctly dubbed, ``the 
worst bill ever,'' and I humbly urge my colleagues to do the same.
  Ms. HIRONO. Mr. Speaker, the U.S. Congress has been grappling with 
how to provide all our citizens with access to affordable, quality 
health care since the time of President Harry Truman. H.R. 3962 
represents a critical milestone in the effort to reform our health care 
system.
  For those who have it, health insurance is not something you can take 
for granted. Every day 14,000 Americans lose their health insurance 
coverage. A recent U.S. Treasury Department report noted that 
approximately half of all Americans under the age of 65 will lose their 
health insurance coverage at some point over the next ten years. 
Thousands are denied coverage because of pre-existing conditions like 
asthma, pregnancy, arthritis, or diabetes. Millions more have no health 
insurance at all, including 54,000 people who live in Hawaii's Second 
Congressional District.
  In his health care speech before Congress and the nation, President 
Obama appealed to the best part of us--to act unselfishly, and to put 
ourselves in the shoes of others. He asked us to imagine what it must 
be like for those who don't have insurance--to live in a State of 
helplessness should illness strike you or the ones you love.
  H.R. 3962 is a bill that will provide for comprehensive health care 
reform that will protect consumers, hold insurance companies 
accountable, rein in health care costs, reduce the deficit, and cover 
36 million uninsured Americans. In supporting this bill, I want to 
highlight three key points. First, for Hawaii the bill includes the 
Hirono Amendment that provides an exemption for Hawaii's Prepaid Health 
Care Act of 1974, which is our nation's first and only employer mandate 
law of its kind. Second, the bill will provide health insurance 
coverage for an unprecedented number of Americans while still reducing 
our deficit. And third, the bill strengthens and improves the Medicare 
program for our seniors.
  First, there is a mistaken perception that everything and everyone in 
Hawaii is exempted under H.R. 3962. That is not so. The Hirono 
Amendment only exempts Hawaii's Prepaid Health Care Act (PHCA) and 
those who come under it (certain full-time employees and their 
employers). PHCA does not apply to part-time employees, seniors on 
Medicare, those without health insurance, government employees, or 
those covered by collective bargaining agreements.
  Therefore, H.R. 3962 would apply to them. I know it is easier to talk 
in terms of the State of Hawaii being exempt from the bill, but that is 
wrong. The distinction between PHCA being exempt and the whole State 
being exempt is a critical distinction to make.
  PHCA requires employers to contribute at least 50 percent of the 
premium cost for single health care coverage, and the employee must 
contribute the balance, provided the employee's share does not exceed 
1.5 percent of his or her wages. Because of rising health care

[[Page 27517]]

costs, Hawaii employers on average cover 94 percent of the premium cost 
because of the second part of Hawaii's law limiting employees' share. 
Hawaii employers may cover the full cost of the health insurance 
premium and many do cover 100 percent of the cost of single coverage. 
H.R. 3962 would require employers to cover 72.5 percent of premium 
costs for single health care coverage.
  Hawaii consistently ranks among the highest nationally in terms of 
insurance coverage and lowest in regard to the number of uninsured. 
This is largely due to PHCA. Private and public health insurance cover 
an estimated 92 percent of our population of 1.3 million people. Of 
those with private insurance, 93 percent are covered through 
employment-based plans.
  Lawrence Boyd, an economist at the University of Hawaii, estimates 
that per capita health expenditures in Hawaii are seven percent lower 
than the national average. Dr. Boyd believes that wider health 
insurance coverage and support for preventive health care lead to this 
outcome. The Hirono Amendment will provide maximum flexibility for 
Hawaii once a federal health care reform bill becomes law. Hawaii will 
be able to decide for itself to retain PHCA or come completely under 
the new federal law.
  Second, H.R. 3962 will ensure that 96 percent of Americans will have 
health insurance coverage. The non-partisan Congressional Budget Office 
(CBO) estimates that the cost of enacting H.R. 3962 will be $894 
billion, consistent with the $900 billion limit established by 
President Obama. The bill is fully paid for. About half of the cost of 
H.R. 3962 is paid for by targeting waste, fraud, and inefficiency in 
the federal Medicaid and Medicare programs. The other roughly half of 
the cost of the bill is paid for through a surcharge on the wealthiest 
Americans--those with incomes above $1 million for couples and $500,000 
for singles; therefore, 99.7 percent of Americans will not be touched 
by this surtax.
  While H.R. 3962 will be paid for, CBO also estimates that the bill 
reduces the deficit by over $100 billion in the first 10 years, and 
continues to reduce the deficit in subsequent years. Leading economists 
from educational institutions across our nation have concurred with 
CBO's findings and support the idea that health care reform promotes 
our country's economic health.
  Finally, I want to address the importance of health care reform to 
seniors. Some of the most damaging misinformation that has circulated 
over the past several months on health care reform is the use of scare 
tactics targeted at seniors. The cynical irony is that the 
misinformation targeting seniors is largely perpetuated by the same 
people who fought the establishment of Medicare and wanted to privatize 
Social Security.
  The truth is that H.R. 3962 will lower prescription drug costs for 
people in the doughnut hole; give the Secretary of Health and Human 
Services the authority to negotiate lower drug prices on behalf of 
Medicare beneficiaries; and extend the solvency of the Medicare Trust 
fund by five years.
  Closing the doughnut hole is an especially critical issue for Hawaii, 
as we have the nation's largest percentage--36 percent compared with 26 
percent--of Medicare beneficiaries who fall into this gap of 
prescription drug coverage. In its first year, H.R. 3962 will reduce 
the doughnut hole by $500 per beneficiary, provide a 50 percent 
discount on brand-name prescription drugs, and phase out the doughnut 
hole by 2019.
  It is remarkable that in just the past two days, over 300 groups 
representing Americans from all walks of life--doctors, farmers, 
seniors, consumers, cancer and diabetes patients--have rejected the 
unsustainable status quo and have endorsed H.R. 3962. In its 
endorsement of the bill, Consumers Union--publisher of the independent, 
non-partisan Consumer Reports--called the health care status quo a 
``consumer crisis with its crippling costs, its unreliability, and lack 
of access,'' and strongly endorsed the House of Representatives health 
care bill because it will create ``a more secure, affordable health 
care system.'' Other groups endorsing the House bill include the: 
American Medical Association, American Nurses Association, AARP, AFL-
CIO, AFSCME, Americans for Democratic Action, American Cancer Society, 
American Diabetes Association, Asian & Pacific Islander American Health 
Forum, Association of Asian Pacific Community Health Organizations, 
National Association of Community Health Centers, National Education 
Association, Campaign for Tobacco-Free Kids, and from my district, 
Lana`i Community Health Center.
  Now is the time to end insurance discrimination based on pre-existing 
conditions or gender. Now is the time to begin to close the Medicare 
doughnut hole for America's seniors. Now is the time to bring change to 
a broken system.
  I urge my colleagues to vote in support of H.R. 3962.
  Aloha and mahalo.
  Mr. THORNBERRY. Mr Speaker, most of us agree that improvements are 
needed in our health care system, especially in the way we pay for 
health care. Health insurance costs have been increasing faster than 
many people can pay, and too many of us do not have health insurance.
  At the same time, many aspects of our health care system are the best 
in the world. We need to work step-by-step to make needed improvements 
while we protect those parts that are improving the quality and length 
of our lives.
  The bill before us, H.R. 3962, takes a very different course. It cuts 
over $400 billion from Medicare and Medicaid, increases various taxes, 
and fines individuals and businesses that do not sign up for the 
government-approved insurance, all to pay for massive new programs, 
including a government-run health insurance plan.
  I believe that this bill will not only fail to stem the growing cost 
of health insurance; it will make health insurance significantly more 
expensive for the 85 percent of Americans who are currently insured. 
And it will severely affect those on Medicare and Medicaid. It will 
also present the largest, most intrusive growth of government into our 
lives in many years.
  The alternative bill is a better approach. It focuses on lowering 
health insurance costs, and CBO agrees that it will do so by up to 10 
percent. At the same time, it makes it easier for those with pre-
existing conditions to obtain coverage. CBO judges that the alternative 
would reduce the federal deficit by $68 billion over the next ten 
years.
  Unfortunately, other ideas have never been allowed to be considered. 
This bill has been railroaded through this House from the beginning. 
That is not the way to deal with an issue as important as health care. 
H.R. 3962 must be stopped so common sense health insurance reform can 
begin.
  Mr. TIAHRT. Mr. Speaker, I rise today to express my opposition to 
both the rule and to the massive government takeover of health care 
that is before us today. There are a large number of issues that I 
could raise, but right now I would like to focus on one of the most 
blatant examples of disregard for the will of the American people found 
within this bill. The bill includes abortions paid for by federal 
dollars.
  For more than 30 years, the United States federal government has not 
been in the business of providing funding for abortion. Since 1976 the 
Hyde amendment has struck a delicate, but respectful balance between 
those who support abortion and those who do not. While it does not make 
abortion illegal, it protects those who oppose abortion from being 
forced to support it with their taxpayer dollars. This is a fair 
compromise that should be included in the H.R. 3962.
  Public opinion is clear on this issue. A number of polls have been 
conducted in the last couple of months confirming that Americans do not 
support federal funding of abortion. A Rasmussen Reports poll from 
September found that only 13 percent of Americans support abortion 
coverage by government-backed health insurance. A Public Option 
Strategies poll from September found that only 8 percent of Americans 
would be more likely to support a health care bill if it included 
federal funding for abortions. A whopping two-thirds of Americans 
oppose using federal dollars to pay for abortions, according to the 
September International Communications Research poll. This is like 
every other aspect of this health care bill--the American people do not 
want it, but Democrat leadership is attempting to ram it down our 
throats anyway.
  This is why I support the Stupak-Pitts amendment. Their amendment 
would extend the same restrictions found in the Hyde amendment to cover 
this bill as well. It does not outlaw or prohibit abortion, or restrict 
those who wish to have an abortion from seeking one. But it does 
prevent federal dollars from being used to pay for those abortions.
  I am pleased that we will be allowed to debate the Stupak-Pitts 
amendment, even without assurance that should it pass, the House would 
retain the language in conference, and I hope that my colleagues vote 
in favor of the amendment. The Republican bill clearly states that 
abortions will not be paid for with taxpayer dollars. I urge my 
colleagues to vote for the Republican bill and against H.R. 3962.
  Mr. ENGEL. Mr. Speaker, I rise in strong support of the Affordable 
Health Care for All Americans Act. In my 21 year career, this is by far 
one of the most important votes I will take. I have spent the past ten 
months meeting with the people of Bronx, Rockland and Westchester 
Counties and have had heartbreaking stories shared with me about the 
inadequacies of healthcare.

[[Page 27518]]

  On this historic day, our Congress honors our country, honors our 
citizens, and honors our moral imperative to provide all Americans with 
comprehensive, affordable access to quality health care.
  This is the reason so many of us get up day after day after day. It 
is the reason why so many of us sought public office, and it is the 
reason why our constituents sent us to Congress--to right the wrongs of 
our broken healthcare system and steer our country back in the right 
direction.
  Never again will families worry late into the night over whether 
their pre-existing medical conditions will prevent their loved ones 
from getting access to health care coverage they so desperately need.
  Never again will insurance companies be allowed to drop coverage for 
those who have paid their premiums diligently, only to lose it when 
they get sick and need it most.
  Never again will families have to worry that if they lose their jobs, 
they will also lose their healthcare coverage.
  The underlying bill provides comprehensive reform to our nation's 
healthcare system and puts our nation back on the road to fiscal 
responsibility by reducing the deficit by $30 billion in the first 10 
years.
  Regardless of who you are, or where you live, this bill provides 
significant benefits to all citizens.
  If you have health insurance, you can keep your doctor and your 
health plan. You like it, you keep it. It's that simple.
  But for those that don't have health insurance, we will change that 
today. Of the 46 million Americans that are uninsured, 85 percent of 
them are in working families. Millions of Americans desperately want to 
purchase health insurance and can't. They've been priced out of the 
system. They have been priced out of a basic desire to keep them and 
their families healthy. 53 percent of Americans postpone care or 
medication because of cost. 60 percent of bankruptcies were related to 
medical debt. It's unfair, unsustainable and un-American to allow this 
failed health care system to continue.
  Insurance companies have a chokehold on the market and we are 
breaking through that today. If you don't have health insurance, or 
lose your health insurance, the new health insurance exchange will 
provide a one stop comparison shopping market place for you of private 
insurance options or a new public health insurance option.
  While in my heart of hearts I believe a single payer system would be 
the best reform of our nation's health care, I have worked tirelessly 
over the last year to enact a strong public option. The public option 
included in the bill will undoubtedly inject competition into the 
market for better prices and coverage of quality health insurance.
  No longer will women be considered second class citizens when it 
comes to healthcare coverage. H.R. 3962 supports women's health care by 
ending the designation of pregnancy, domestic violence and caesarean 
sections as pre-existing conditions, and eliminating out-of-pocket 
expenses for preventive services including mammograms, well baby and 
well-child care visits. It also prohibits plans from charging women 
more for health coverage than men, and guarantees coverage for 
maternity care.
  H.R. 3962 invests in Medicare. Our seniors will see improved 
benefits, free preventive care, better primary care and lower drug 
costs. The donut hole, in which seniors pay monthly premiums for drug 
coverage without a drug benefit, will finally be closed. I have been 
fighting for this since the day we enacted the Medicare Prescription 
drug benefit.
  Young adults will have more access to affordable healthcare than ever 
before. Our bill allows adults to stay on their parents' healthcare 
plans until their 27th birthday. This measure alone will cover one out 
of three uninsured young adults.
  Additionally, small business owners will be granted access to 
affordable large group rates in the new insurance exchange and tax 
credits to help businesses insure employees across the 17th district 
and our nation. I met with the Rockland Small Business Association this 
summer and fought to make health insurance reform workable for small 
businesses. 98.8 percent of small business owners will pay no surcharge 
and 86 percent of America's businesses are exempt from the shared 
responsibility requirement to provide insurance. In fact, businesses 
with payrolls of $500,000 or below are completely exempt from 
provisions in H.R. 3962.
  Throughout this year, and in my role as the Senior New Yorker on the 
Energy & Commerce health subcommittee, I have worked hand and hand with 
Chairmen Waxman, Rangel, Miller, Majority Leader Hoyer and Speaker 
Pelosi to improve the underlying bill for New York State and people 
nationwide.
  Here are just a few of the provisions I was successful in inserting 
in the underlying bill.
  I am proud to have reformed the Medicaid program to serve people with 
HIV. Under current Medicaid rules, low-income people with HIV must wait 
until they are disabled by AIDS before they can get covered by 
Medicaid. In the House bill, states could cover all people with HIV 
infection under state disability income and resource levels until 
January 1, 2013, when the new health insurance exchange is operational, 
at an enhanced federal match.
  I worked to protect the ability of eight states, including NY to 
preserve Adult Day Health care programs in Medicaid. These community-
based long term care programs provide comprehensive health care 
services in day settings.
  Beneficiaries are given nursing, case management, clinical 
management, medical, diagnostic, social, rehabilitative, recreational 
and personal care services on a routine, daily basis.
  Since my time in the New York State Assembly when I was the Chair of 
the Assembly Committee on Alcohol and Drug Abuse, I have been 
championing for mental health and substance abuse services. I worked to 
strengthen our capacity to serve people affected by these disorders 
through Federally Qualified Behavioral Health Centers. My provision 
will establish national standards of care for persons with serious 
mental illness and addiction disorders. Furthermore, new reporting and 
accountability standards for mental health care will better integrate 
its providers and services within the larger healthcare system.
  Many people have a family member, or are friends with someone who has 
autism. I worked with Rep. Doyle, the Co-Chairman of the Congressional 
Caucus on Autism on several provisions dear to me. We ensured that 
discrimination in benefits against persons with autism are prohibited 
by including behavioral health treatments as part of the essential 
benefits package in the House health reform bill.
  There is currently a shortage of appropriately-trained personnel who 
can assess, diagnose, treat and support patients with Autism Spectrum 
Disorders (ASD). These professionals require the most up-to-date 
practices to best care for those with autism and their families. And so 
we included a provision for the training for professionals working with 
children and adults with autism.
  I advocated to improve the healthcare for maternity and newborn care 
in the Medicaid program. H.R. 3962 will extend important child health 
quality improvement provisions to traditional-eligible childbearing 
women and newborns and other covered adults younger than age 65. As a 
result of my provision, the Secretary of Health & Human Services will 
collect data and make recommendations on improving care for these key 
populations.
  Finally, I was tireless in my advocacy for the Disproportionate Share 
Hospital (DSH) program, which assists with the cost of caring for 
uninsured and underinsured people at hospitals. These payments ensure 
that hospitals are not in financial distress from serving low-income 
people.
  We stand here as proud Americans determined and ready to transform a 
broken health care system into a model of care worldwide. The cost of 
inaction is too great. Today, we answer the call of history, and vote 
for health insurance reform for America. Our nation's future depends on 
it.
  Mr. SCOTT of Virginia. Mr. Speaker, all afternoon we have heard about 
the ``freedom'' to be uninsured. Seniors in my district do not want us 
to repeal government run Medicare so that they can enjoy a ``freedom'' 
to be uninsured, and those without insurance now do not view themselves 
as enjoying some ``freedom''; they want insurance.
  The Republican substitute responds to the comprehensive Affordable 
Health Care for America act with a bill that fails to reduce cost, 
fails to cover uninsured Americans, and it may study--but it does not 
help--those with pre-existing conditions. It does, however, attack 
innocent victims of medical malpractice.
  One recent study showed that medical malpractice represents less than 
one-third of one percent of all health care costs. And yet the 
Republican substitute seeks to blame our broken health care insurance 
system on innocent victims of medical malpractice. For those victims, 
the bill limits the ability to hire a lawyer, complicates the lawsuit, 
shifts the costs of medical malpractice from the doctor to the victims' 
own private insurance, and in some cases causes the injured victims to 
lose the right to sue before they even know they've been injured. I'd 
like to share some specific examples of the egregious provisions 
included in the Republican substitute.
  Under the Republican substitute, a young child whose life is forever 
devastated by medical malpractice can lose all right to sue on his

[[Page 27519]]

or her eighth birthday--long before he or she reaches legal age to make 
his or her own decision.
  Under the Republican substitute, when two or more wrongdoers act 
together, and one of them is able to flee or put their assets out of 
reach, the innocent victim is left short, while the other wrongdoer is 
shielded from full responsibility. They call this the ``fair share 
rule.''
  Under the Republican substitute, it is more difficult for a medical 
malpractice victim to get a lawyer's help to fight against the 
insurance companies, because the bill permits a court to reduce the fee 
paid to the victim's lawyer--after the case has been fought and won. 
This provision penalizes victims with winning cases. One would think 
the purpose of this provision is to save the insurance carrier money 
and thereby reduce malpractice premiums; however, insurance carriers 
are not responsible for the victim's lawyer's fee. Insurance carriers 
are responsible for the defendant's lawyer's fee, so permitting the 
court to reduce fees paid to defendant's lawyers would actually save 
money and reduce premiums. The substitute does not allow that. This 
makes no sense. Under current practice, the victim's lawyers already 
don't get paid if the victim loses. Now they might not get paid even if 
the victim wins.
  Under the Republican substitute, if the victim has health insurance 
that helps pay for the victim's care while the victim is waiting for 
the wrongdoer to be held accountable, the wrongdoer can escape legal 
accountability for that part of the cost entirely. The wrongdoer gets 
to shift the cost onto the victim's own health insurance. That's the 
Republican approach to health insurance reform--saddling the victim's 
insurer with the cost of someone else's negligence, while letting the 
wrongdoer off the hook.
  Under the Republican substitute, the only time punitive damages would 
ever be available is when the wrongdoer has maliciously injured the 
victim that is, when the wrongdoer has committed a violent felony. And 
even then--even in cases of the most heinous violence imaginable--the 
Republican substitute caps punitive damages.
  The Republican substitute is empty of any meaningful health insurance 
reform, and it is utterly callous to malpractice victims. None of these 
unfair provisions were passed during previous attempts when the 
Republicans controlled the House, the Senate and the White House, and 
they should not be passed now. The substitute should be defeated.
  In contrast, the majority's Affordable Health Care for America Act 
reduces the number of uninsured, increases accessibility of health 
care, controls skyrocketing costs, and addresses the denial of coverage 
based on pre-existing conditions. This legislation will put us on a new 
path where health care will be affordable to all and not just a luxury 
for some, and I am proud to support this historic health insurance 
reform legislation.
  Ms. NORTON. Mr. Speaker, I support the Affordable Health Care for 
America Act both because of the extraordinary step forward it brings 
the nation and my district, the District of Columbia. First, I took 
steps to assure that the Affordable Health Care for America Act we 
expect to pass tonight would treat the District equally with the 50 
states (although it does not do so for the territories). Consequently, 
the bill will provide coverage for 14,000 uninsured D.C. residents and 
affordable credits to help up to 134,000 D.C. families pay for 
coverage; will improve employer-based coverage for 363,000 District 
residents; will improve Medicare for 75,000 D.C. seniors, including 
closing the prescription drug donut hole for 3,300 seniors, as well as 
providing free preventative care and wellness check-ups for all 
seniors; will allow 22,200 D.C. small businesses to obtain affordable 
health care coverage; and will save about 400 District families from 
bankruptcy resulting from unaffordable health costs. The bill also will 
reduce the cost of uncompensated care by $126 million for the 
District's besieged hospitals and health care providers.
  I am proud of the remarkable advances made by our bill, even though 
it does not meet all that I pressed to achieve. The Congress, of 
course, is not known for perfect bills, but the extraordinary diversity 
of our Democratic Caucus--from right to left--has assured that this 
bill represents a cross-section of the American public--urban, 
suburban, and rural. The incredible diversity of the Democratic Caucus, 
representing Republican, right-leaning, moderate, and progressive 
areas, meant that we could go to the floor only with a bill that 
sensitively put all of America together into one convincing bill. That 
is why we have produced a bill that satisfies deficit hawks, more wary 
of increasing deficits than of most other issues as well as single-
payer advocates, who believe that only Medicare for all can 
sufficiently reduce costs while providing adequate health care to the 
middle class and the uninsured. Thus, there can be no doubt that the 
Affordable Health Care for America Act is a balanced bill.
  The bill's greatest achievements are that it will reduce the deficit 
over the next 10 years and into the future while covering 96 percent of 
the American people; will end discrimination by insurers who dropped or 
refused to renew or sell coverage because of health status; and will 
ensure that coverage is affordable by providing subsidies for people in 
employer-based health care or through the insurance exchange of private 
insurers as well as a consumer option to drive down the cost of health 
care while operating on a level playing field with other insurers.
  I particularly support this bill because it will take off the burden 
that the District of Columbia heroically took on, beginning with the 
Williams administration, to offer health care to the uninsured, without 
any assistance from the federal government, rather than subject them, 
as well as the District, to costly emergency room care, the most 
expensive available. The District's Health Care Alliance, which 
provides insurance to more than 50,000 residents lacking health 
insurance, who do not qualify for Medicaid or Medicare, is collapsing 
under the weight of increasing requests from individuals without 
insurance. The city had to cut its Health Alliance budget this year to 
46,000 individuals, although a year ago 48,000 individuals had 
registered and 55,000 were expected to register in the 2010 fiscal 
year.
  At my ``Fact Check Town Hall Meeting on Health Care Reform,'' which 
observers said was notable for its civility and the diversity of 
residents attending, it was apparent that District residents strongly 
support the approach taken by today's bill. By September, my office had 
received 2,000 contacts on health care reform, almost all supporting 
the reform efforts underway in the House, with only nine residents 
expressing opposition to any reform. Also, 276 District residents had 
written in opposition to parts of the proposed bill, and 220 of them 
opposed the public plan. Most who opposed the public plan, appeared to 
believe that such a plan would affect their employer-based plans, which 
this bill ensures cannot happen.
  I believe that this bill is strong and compelling enough to offer 
stiff resilience to those who have been unwilling to take on the 
special interests and who may now believe their best hope is in the 
other body. Tonight, this bill provides the best hope for the health 
care of our nation's longsuffering people.
  Mr. PAULSEN. Mr. Speaker, like many of my colleagues on both sides of 
the aisle, I believe the status quo of our nation's health care is 
unacceptable. We need real reform in this country that will lower costs 
and keep health care decisions in the hands of patients and their 
doctors.
  This bill would establish a new government run bureaucracy and a 
public-plan that will drastically expand the role of government into 
personal health care, at a massive cost of more than $1 trillion. And 
it's important to note, that like nearly every other entitlement 
program, the costs from this bill will only skyrocket.
  The bill raises taxes on small businesses, individuals and medical 
devices like pacemakers and stents. Indeed, this bill would impose 
$729.5 billion in higher taxes. $135 billion in taxes will be levied on 
business. $20 billion in taxes will be levied on medical device 
manufacturers. Using President Obama's economic measuring stick, as 
many as 5.5 million jobs could be lost from the taxes in this bill.
  We all heard over and over again that, ``those of you who like your 
health care plan can keep it.'' What is not mentioned is that every 
plan will need to meet government requirements for a government seal of 
approval. This plan cuts $500 billion in Medicare benefits to seniors, 
including over $170 billion in cuts to Medicare Advantage--a plan that 
is used by more than 19,000 seniors in my district. These seniors will 
no longer get the same care and coverage that they need.
  Mr. Speaker, in the bill before us there is no provision in this bill 
to allow small businesses to pool together, no protection for those who 
want keep the coverage they have, and no medical liability reform.
  The health care plan I support lowers health care premiums for all 
Americans, guarantees affordable coverage for patients with preexisting 
conditions, protects seniors, Medicare benefits, includes no tax 
increases, enacts real medical liability reform, empowers the doctor-
patient relationship, and reduces the budget deficit.
  I also want to point out that I offered five amendments to the 
healthcare bill, but none were made in order. The first amendment would 
have removed the onerous medical device tax from the bill and replaced 
it with unobligated stimulus funding. It makes no sense

[[Page 27520]]

to me that this bill taxes innovation and our job creators and takes 
away funding for life saving technology.
  I had another amendment that would have required a study of the 
harmful effects the innovation tax would have on the medical technology 
industry. Americans should know the implications of the negative 
effects on life saving technologies in this nearly 2,000 page bill.
  Yet another amendment I offered would have removed the seasonal and 
temporary workers from the employer mandate. This amendment would have 
helped to lessen the heavy burden this legislation imposes on small 
businesses.
  In addition, I offered an amendment that would have improved and 
expanded health savings accounts. This would have helped make health 
care more affordable for the millions of people covered by high 
deductible health plans.
  Finally, I offered an amendment to clarify that nothing in this bill 
would have infringed on the healthcare that was promised to our 
nation's veterans. Unfortunately, this health care bill makes massive 
changes and our nation's veterans are owed the assurance that they will 
have adequate care.
  Mr. Speaker, I would like to close by saying that I oppose this bill 
because it puts the government in between the decisions of a patient 
and their doctor. This is simply unacceptable. Patients should have the 
right to make their own choices regarding the medical care they need 
without government interference. Whether it is taking care of your 
children, parents or grandparents, there is no issue that is more 
personal to a family than health care. No special interest group, 
Member of Congress or federal bureaucrat should stand between a patient 
and their doctor.
  Americans continue to lose jobs and faith in their American 
government each day. This bill is not only the wrong direction for our 
economy but also the wrong direction for America.
  Mr. BISHOP of Georgia. Mr. Speaker, after months of studying the 
various proposals, listening to feedback from my constituents on both 
sides of the issue in town hall meetings, informal discussions, 
letters, e-mails and faxes, and after prayerful reflection, I concluded 
that I must support the health care reform legislation. I believe it 
would improve the lives of my constituents by ensuring that they have 
access to quality, affordable health care. H.R. 3962, while not 
perfect, makes substantial progress in this regard.
  During my town hall meetings on health insurance reform last August, 
I said that we have a moral obligation to ensure that all Americans 
receive the health care they need to live healthy and productive lives. 
I have long been concerned about the poor health indicators among my 
constituents, and this evening I cast a vote that I believe will have a 
significant impact on improving the lives of Southwest Georgians now 
and into the future.
  Georgia ranks third in obesity rates for children age 10-17; sixth in 
the number of tuberculosis cases; seventh in number of low birthweight 
babies; ninth in diabetes rates for adults; tenth in the number of 
uninsured; eleventh in hypertension rates; eleventh in the number of 
new cancer cases; and fourteenth in obesity rates for adults. These 
numbers are unacceptable.
  H.R. 3962, when signed into law, will immediately bring about reforms 
that will benefit the citizens of Georgia's Second Congressional 
District and all Americans. The bill will immediately begin to close 
the donut hole in the Medicare part D prescription drug coverage for 
seniors. It will outlaw denial of coverage for people with pre-existing 
conditions, limit premium discrimination based on gender and age, and 
prevent insurance companies from dropping coverage when people develop 
serious illnesses and need it the most.
  In addition, the bill increases funding for community health centers 
and other primary care providers, doubling the number of patients seen 
over five years. It will extend coverage for young people to stay on 
their parents' insurance plans up to their 27th birthday. It will 
extend COBRA health insurance coverage for displaced workers. 
Furthermore, it will hinder price-gouging by requiring that insurance 
companies disclose rate increases.
  By 2013, when the mandate for coverage and the Exchange are in place, 
additional provisions will take effect including no more co-pays for 
routine checkups and preventive care, yearly caps on individuals' out-
of-pocket expenses and no lifetime caps on what insurance companies 
will cover.
  In addition to the benefits for Southwest Georgia, the bill will 
reduce the federal budget deficit by $104 billion over the next decade. 
It will allow states to form compacts that will enable consumers to buy 
policies from insurers across state lines.
  With regards to small businesses, the health care legislation will 
provide tax credits to nearly 14,000 small businesses in the Second 
Congressional District who offer their employees coverage and exempts 
86 percent of small businesses (those with payrolls of less than 
$500,000) from having to provide coverage, and continues the business 
deduction for those who do.
  Finally, the House health care bill prohibits the use of federal 
funds for abortions. It also requires verification of citizenship or 
lawful presence for undocumented immigrants to receive coverage.
  I look forward to further improvements as the bill is considered by 
the Senate and the Conference Committee, where differences between the 
House and Senate bills will be resolved. But this evening's vote is a 
significant step towards affordable, quality health care for all.
  Mr. KENNEDY. Today is truly a historic day for all Americans, and as 
an elected official of this great democracy, it is an extremely proud 
day for me. It is an occasion to celebrate and thank all those who 
fought to protect our nation's democratic process. It is also an 
occasion to recognize and remember all those Americans who have 
suffered waiting for this day to arrive. We have worked together to 
achieve this goal of quality, affordable health care for all Americans. 
To all these people, I express my sincere gratitude, and I rejoice with 
you today that a new chapter in our history has begun.
  The Affordable Health Care for America Act creates basic protections 
for all Americans seeking access to healthcare. No longer will insurers 
be able to drop you from your insurance when you get sick, nor can they 
deny you coverage for a pre-existing condition. A public option will 
offer a choice for consumers and provide real competition to keep 
private insurers honest. Affordability credits will help individuals 
and small businesses to purchase health insurance. Additionally, these 
reforms are fully paid for and will actually lower the deficit over the 
next 10 years.
  I am proud that the final version of this legislation includes 
numerous provisions I have long advocated for and worked with my 
colleagues to achieve. While the initial draft of the Affordable Health 
Care for America Act gradually closed the donut hole for Medicare 
prescription drug coverage over 15 years, I am pleased to have worked 
with the Speaker to successfully reduce the timeline in which this 
critical reform will take place. The donut hole will now begin to close 
immediately and will close completely by 2019, providing much needed 
assistance and relief to seniors starting next year.
  Likewise, I am also pleased that the Affordable Health Care for 
America Act eliminates lifetime caps, provisions of many health 
insurance plans that limit the total dollars in benefits that the 
insurance plan will pay out over the lifetime of an enrollee in the 
plan. I authored a letter, signed by 23 of my colleagues, urging this 
lifesaving provision to become effective immediately. I am pleased that 
the elimination of lifetime caps on insurance has been made effective 
in 2010, so that none of the 25,000 individuals who reach their 
lifetime caps each year will die waiting for the provisions to take 
place.
  A key aspect of this legislation that is of particular importance to 
me is the extension of the mental health parity protections established 
into law last year by my legislation, the Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act. Not only are 
these protections extended to all plans in the Health Insurance 
Exchange, but mental health and substance use benefits are a part of 
the essential benefits package created by this legislation. For 67 
percent of adults and 80 percent of children needing mental health care 
that do not receive it, this victory cannot be understated. I commend 
my colleagues and my fellow citizens for their leadership in 
recognizing that the health of the mind truly cannot be separated from 
the health of the body. Today marks a new day and a giant leap forward 
towards our transition from a ``sick care'' system to one which is 
preventive, collaborative, and patient-centered.
  Along these lines, I have also worked closely with my colleagues to 
ensure that mental health and substance use screening tools, such as 
Screening, Brief Intervention and Referral to Treatment (SBIRT), were 
included in this legislation. Severe mental illnesses are estimated to 
cost the U.S. hundreds of billions annually in lost wages. Screening 
for mental health and substance use has proven to be a significant cost 
saver for our health care system. The Affordable Health Care for 
America Act establishes a program to provide grants to support these 
critical services.
  I will continue to work with my colleagues to ensure that our health 
care professionals have the tools that are needed to recognize mental 
health and substance use in their patients. This means ensuring that 
mental health and

[[Page 27521]]

substance use education be required of all health care professionals 
and integrated into the medical curricula, continuing medical 
education, and licensing examinations. It also includes addressing the 
drastic shortages of child and adolescent mental health professionals 
by providing loan forgiveness and making grants to professional schools 
to develop, expand, and improve training programs for professionals who 
serve children and adolescents. Language to this effect is included in 
some of the Senate healthcare reform legislation, and I will work with 
my colleagues to ensure that these critical provisions are retained.
  Again, I commend my colleagues, the leadership, and my fellow 
Americans for their steadfast effort, diligence, and tremendous 
stewardship towards realizing the dream of quality, affordable health 
care for all Americans.
  Mr. SMITH of New Jersey. Mr. Speaker, like most Americans, I believe 
we urgently need health care reform to provide every American access to 
high-quality medical care.
  During the long and painful illnesses of both my parents, I had to 
fight with their health management organization to get them the care 
they deserved. Their HMO put my family through months of frustration 
and anguish. I know I'm not alone--tens of millions of Americans have 
gone through this as well. It's not right, and it's time to change 
that. Americans need more protection, power, and say in their health 
care programs, and they need us to reform the system to make it more 
affordable for everyone.
  Regrettably, H.R. 3962, the bill before the House tonight, not only 
falls short, but it will make most people's health care worse, and it 
will certainly disempower all of us. For this reason I strongly oppose 
the bill--H.R. 3962.
  After carefully studying H.R. 3962, I am concerned that the bill is 
actually a step backwards--many patients will have less, not more, 
access to and say over their health care if H.R. 3692 is enacted. I 
firmly believe we can and must reform our health care system and 
provide better solutions for those currently uninsured or underinsured. 
But we must do so without jeopardizing the quality of health care for 
these currently insured people and families, many of whom will see 
their own health care access and quality seriously eroded under the 
bill.
  H.R. 3962 will:
  Limit patient access by establishing federal bureaucracies with new 
authority to determine what medical treatments and services will be 
covered at, what costs patients will pay--Americans will be so 
disadvantaged that this bill makes those who don't purchase 
``acceptable'' coverage (as defined by the federal government) subject 
to fines and imprisonment up to 5 years.
  Cause most Americans to lose access to their current health insurance 
coverage and force them into a nationally uniform public plan. It will 
do this by subsidizing a government-run ``public plan'' that will 
ultimately drive private health plans out of business. Most Americans 
don't want to lose their current insurance, and they trust the public 
plan even less than they trust private insurance, which at least has to 
compete for customers, and permits them to choose their doctors. This 
would hit my constituents especially hard--according to the Urban 
Institute, approximately 90% of the people in my district currently 
have health coverage;
  Slash payments to health-care providers, threatening the continued 
existence of many hospitals, home health and skilled nursing facilities 
serving New Jersey residents.
  Mr. Speaker, throughout my career in Congress, I have been a 
steadfast supporter of Medicare for our senior citizens and the 
disabled. I have voted several times to preserve and protect Medicare 
even when I stood alone in my own party rejecting a proposal to cut 
$270 billion from Medicare in 1995.
  That is why I find it absolutely unacceptable that H.R. 3962 cuts 
Medicare by a whopping $500 billion. Proponents argue that some funding 
will be returned through other avenues. But even if that were true, 
Medicare will still be drastically cut by a net of $219.4 billion, in 
their ``best case scenario.''
  The bill also guts Medicare Advantage plans, which offer additional 
coverage to over 11 million seniors--15,983 in my district alone--who 
choose Medicare Advantage plans as the coverage that best meets their 
needs.
  I will not vote for massive cuts in Medicare. These cuts will wreak 
havoc on our nation's health care system and everyone it serves, 
particularly the seniors and disabled. We need reform legislation that 
respects all human life, the most vulnerable among us which includes 
the frail and the disabled of all ages.
  Finally, this bill will hinder economic recovery and job creation 
during a major recession. Just yesterday the nation's unemployment rate 
rose above 10 percent for the first time since 1983, and if you include 
those who have stopped looking for jobs and those who can only find 
part-time work, the rate is 17.5 percent. The bill does additional harm 
by:
  Raising taxes on individuals and small businesses by $729.5 billion;
  Failing to reform our costly and unfair system of medical liability 
lawsuits, which inflates health care costs by billions of dollars each 
year, exceeding 10% of all health care expenditures;
  Mandating a $34 billion expansion of state Medicaid payments--in 
order to cover this massive increase, financially strapped states like 
New Jersey will have to cut other services; and
  Costing the taxpayer, according to the Congressional Budget Office 
(CBO), $1.3 trillion over ten years and using budget gimmicks and tax 
increases to cover that cost.
  I must mention two other serious problems with the bill:
  It does not adequately protect the freedom of conscience of health 
care providers and sets up mechanisms that ration care by creating 
government ``waiting lists'' if there are insufficient funds to pay 
expenses; and
  It does not require patients to verify their identity, which, 
according to the CBO, means that millions of undocumented immigrants 
will receive free health care, unfairly subsidized by taxpaying 
citizens.
  It is truly unfortunate that the Democratic leadership did not work 
to put forth a health care reform bill that addressed these concerns. 
We need a proposal that advances solutions rather than creates new 
problems. Let me be clear, I take a back seat to no one when it comes 
to working to ensure that the federal government accepts its role and 
is doing its part in helping people and providing a health care safety 
net for those in desperate need of health care support. I am proud of 
my record, voting to defeat cuts to and expand existing federal health 
care programs, while working to protect patient rights and the delivery 
of quality medical care. These efforts include:
  Medicare/Medicaid/SCHIP. I support providing our senior citizens a 
high level of benefits under the Medicare program. On one occasion, I 
voted against a $270 billion reduction in Medicare spending. One reason 
I cannot support the current health care legislation is because it 
makes over $500 billion in cuts to Medicare. To expand health insurance 
to more uninsured low-income children, I voted in 1997 for legislation 
creating the State Children's Health Insurance Program (SCHIP) and 
voted last year to expand the program. SCHIP and Medicaid together 
cover more than 30 million low-income children, as well as 16 million 
adults, 6 million seniors, and 10 million persons with disabilities. 
That is why I have been so adamant about protecting those programs.
  Community Health Centers. Federally designated community health 
centers are another effective means to get affordable health care to 
underserved communities. The health centers program includes community, 
migrant, homeless, and public housing health centers and provides 
primary and preventive care to more than 18 million individuals at over 
3,700 sites located in every state and U.S. territory. I have been a 
consistent supporter of increased funding for the community health 
centers program. A significant factor in the success of community 
health centers is that they are managed at the community level with a 
concern for serving their clients in their local neighborhoods.
  Veterans Health Care. As former Chairman of the House Committee on 
Veterans' Affairs, I fought successfully (and sometimes nearly alone) 
to provide increased medical services and funding for veterans health 
care programs. I wrote several laws to boost and expand veterans health 
care, including the Department of Veterans Affairs Health Care Programs 
Enhancement Act (PL 107-135), which expanded and enhanced veterans' 
healthcare services and reduced out-of-pocket costs for low income 
veterans by 80 percent and continues to help disabled veterans obtain 
the tools they need to live fuller lives. I also wrote the law, the 
Veterans Health Programs Improvement Act of 2004 (PL 108-422), that 
created 5 poly-trauma centers within the VA, and an additional 17 
networked sites, that specialize in treating complex multi-trauma 
injuries--including severe brain injury--associated with combat 
injuries from Iraq and Afghanistan.
  Health Care Caucuses. Working with my colleagues across the aisle, I 
have cofounded and currently co-chair important bipartisan health care 
working groups, i.e. caucuses, which aim to educate Members of Congress 
and increase federal resources and research on treatments and cures for 
specific diseases, some which effect New Jersey residents 
disproportionately. For instance, I serve as co-

[[Page 27522]]

chairman of the bipartisan Congressional Alzheimer's Task Force; the 
Coalition for Autism Research and Education; the Spina Bifida Caucus; 
and the Lyme Disease Caucus. Each caucus has served as an effective 
forum to advance legislation that helps families combating health care 
challenges;
  Patients Rights. As far back as 2001, I cosponsored and voted for the 
Patient Protection Act which contained critical patient protections to 
help put doctors and patients back in control of their health care 
decisions, rather than bureaucrats at managed care companies. 
Unfortunately, while separate bills passed the House and the Senate, 
they were never signed into law.
  Insurance Reform. I voted for the Health Insurance Portability and 
Accountability Act of 1996 (HIPPA), which provided insurability 
protections for individuals moving between insurance plans in the 
individual or group markets and reduced or eliminated preexisting 
medical condition exclusion periods for such individuals. I have also 
been a strong advocate for allowing small businesses, associations, and 
non-profit organizations to band together to purchase health insurance. 
In acquiring health insurance, small businesses do not enjoy the 
benefits of economies of scale of large businesses, which allows those 
large businesses to spread administrative costs over a large base and 
provide significant leverage in negotiating lower premiums. Over 50 
percent of the nation's uninsured are employed in a small business or 
are a dependent of such a worker.
  Medical Malpractice Reform. The House of Representatives has voted to 
pass medical liability reform legislation with my support eight times 
in the past 15 years. These bills--which sought to place a cap on non-
economic damages, limit punitive damages, and restrict attorneys' 
fees--were modeled after a California law that many credited for 
relatively low malpractice premiums in the state.
  While we have had some significant successes in these critical areas 
expanding--frequently after much toil--it is indisputable that more 
comprehensive changes are needed, including major reforms of the 
private health insurance market.
  The goal of responsible health care reform should be to provide 
credible health insurance coverage for everyone, strengthening the 
health care safety net so that no one is left out, and incentivizing 
quality and innovation, as well as healthy behaviors and prevention. 
This means that the current private health insurance market will have 
to be reformed to put patients first, and to eliminate denials for pre-
existing conditions and lifetime caps and promoting portability between 
jobs and geographic areas, including across state lines. The tax code 
should be modernized to promote affordability and individual control, 
provide assistance to low-income and middle-class families. Medicare 
requires reform to be more efficient and responsive, with sustainable 
payment rates.
  Of course responsible health care reform will respect basic 
principles of justice: it will put patients and their doctors in charge 
of medical decisions, not insurance companies or government 
bureaucrats. It will also ensure that the lives and health of all 
persons are respected regardless of stage of development, age or 
disability.
  The Republican alternative amendment does these things. It focuses on 
lowering health care premiums for families and small businesses, 
increasing access to affordable, high-quality care, and promoting 
healthier lifestyles--without increasing taxes or adding to the 
crushing debt Washington has placed on our children and grandchildren 
and without cutting Medicare. It also establishes a real conscience 
protection for health care providers and it requires verification of 
citizenship and identity.
  I oppose H.R. 3962 because in many ways it jeopardizes coverage for 
those who already have it, especially seniors and the disabled. At the 
same time it exercises far too much top-down government control, 
forcing everyone toward a government plan, controlling exactly what 
sort of care will be offered. For this reason I support the Republican 
alternative amendment. It moves significantly in the right direction 
while applying the wisdom of Hippocrates' first principle of medicine: 
doing no harm.
  Mr. SCHRADER. Mr. Speaker, I am proud to have cast an historic vote 
to overhaul America's failing health care system today. Controlling 
escalating health care costs is essential to getting our nation's 
fiscal picture under control. For the first time in our country's 
history it has brought consumers, businesses and providers to the table 
in a united effort to control costs, make health care affordable and 
improve our health outcomes. I have always said that if you like your 
current health care you need to be in favor of reform because you will 
not be able to afford that same level of care if the status quo 
persists.
  H.R. 3962 prohibits exclusions based on preexisting conditions. It 
forbids the cancellation of your health care because you have suffered 
an illness or injury. It makes sure that everyone shares appropriately 
in the benefits and costs of affordable health care reform. Americans 
will no longer be one illness or job loss away from bankruptcy. It 
guarantees basic benefits for all Americans and allows competition 
across state lines to reduce costs.
  H.R. 3962 makes major reforms in our health care delivery system that 
we have not had the political courage to do for years. Major 
improvements in Medicare and Medicaid save over $400 billion while 
still expanding services to our seniors. I am pleased the House bill 
contains a section on Comparative Effectiveness Research (CER). 
However, I believe the CER provisions contained within the bill could 
use significant improvement to ensure the research that is conducted is 
protected from undue political influence from the government. Earlier 
this year I introduced H.R. 2502, the Comparative Effectiveness 
Research Act of 2009. My bill reinforces a core principal of health 
care that patients and doctors should be making medical decisions. It 
would establish an independent institute charged with coordinating and 
guiding comparative effectiveness research programs. By streamlining 
access to the latest medical research, doctors can make sound decisions 
that will improve the health of their patients and ultimately lower 
costs by reducing the number of redundant and ineffective treatments. 
This is the approach that has guided CER efforts in the Senate and it 
is my intention to work closely with the House leadership and the 
conference committee to ensure any final compromise establishes a 
public-private institute outside of government to guide the research 
and ensure it will be independent, credible, and protected from 
political influence.
  It begins to emphasize, and pay for early, intervention and 
prevention to keep people healthy and reduce costs. H.R. 3962 puts $34 
billion is put into wellness and prevention programs and developing the 
primary care network needed to provide timely service to all Americans. 
Rural America also gets particular attention in the bill with loan 
forgiveness and incentive programs.
  America's senior citizens do particularly well under this 
legislation. In addition to modernizing and reducing costs, Medicare 
improvements allow seniors to keep more assets and still access 
subsidies. The new bill fixes the donut hole sooner and allows more 
drug price- negotiation to ensure seniors are getting the best prices 
for their medication. In a separate bill Congress fixes doctor 
reimbursement so that a 21 percent rate reduction is avoided and 
doctors become more willing to take senior Medicare patients again.
  Private employer-based health insurance would still constitute 60 
percent of the way Americans get their health care. This bill provides 
a public option with negotiated rates and without tax-payer subsidies 
that will drive down costs without creating an uneven playing-field 
with private insurance companies.
  H.R. 3962 does better by small businesses too. Small businesses with 
payrolls below $500,000 are excluded from having to provide health care 
or pay penalties. The old bill set that limit at $250,000. And only 
individuals earning over $500,000 and families over $1 million would be 
subject to the surcharge for incomes over those amounts.
  Oregon does particularly well in the new bill. Not only are many of 
our pioneering health care delivery systems included in the bill with 
grants for expanding, but two studies create a Congress proof 
opportunity for the restructuring of Medicare reimbursement that will 
reward high-quality low-cost states like Oregon.
  Perhaps most significantly H.R. 3962 substantially reduces the cost 
of the initial reform bill. Almost $200 billion is trimmed from the 
costs, with more to come in negotiations with the Senate and President 
Obama. According to CBO, the bill reduces the deficit both in the 
short- and long-term. According to leading economists, the bill lowers 
premiums going forward compared to current law for all income groups, 
even those without subsidies.
  I believe we can do better! I have personal commitments from the 
President that more cost containment is necessary and will occur as we 
work with the Senate. The Senate subsidies are much more sustainable 
over the long-term and strike a better balance between making health 
care affordable and curbing the overutilization through meaningful cost 
sharing.
  I am excited about reforming our health care system to deliver better 
health outcomes and more affordable costs for families, businesses and 
our Nation.
  Ms. ESHOO. Mr. Speaker, I come to the floor today to cast one of the 
most important votes of my congressional career--a vote in

[[Page 27523]]

support of H.R. 3962, the Affordable Health Care for America Act.
  We are on the threshold of history that has been a half-century in 
the making.
  The promise of America as a land of equality and opportunity that 
embraces and cares for all of its citizens is but an empty promise 
without the guarantee of healthcare and the freedom from financial 
devastation resulting from illness.
  For so many of us, this long battle has had a singular, courageous 
champion who has fought like a lion for the sick, the elderly, the left 
behind and the left out. Our great achievement today will also be our 
greatest memorial to our friend, mentor and inspiration, Senator Edward 
Kennedy.
  Like Senator Kennedy, many of us wondered--as the decades marched 
by--whether our efforts for comprehensive healthcare reform would ever 
be successful.
  His unwavering commitment to decent healthcare for all Americans has 
paved the way for the bill before us today. It is on the shoulders of 
this giant that we stand and I pledge my vote as a tribute to the late 
Senator.
  At the heart of this legislation is one simple, indisputable idea: 
Everyone deserves health insurance they can afford.
  Our system is broken. In a nation where health is a daily value and 
where health care is the finest in the world, I hear daily from 
constituents who cannot afford to take care of themselves or their 
families, who are driven out of the system by skyrocketing premiums, 
who live under the threat of a shuttered business or a bankrupted 
household, or who simply have to roll the dice and hope they will get 
better--or not too much worse.
  Perhaps most tragically, our current system turns its back on those 
most in need--those with a pre-existing condition. Health insurance is 
meaningless if it's only available to the healthy.
  H.R. 3926 will cover 96 percent of all Americans.
  It prohibits discrimination based on pre-existing conditions.
  It eliminates lifetime caps--immediately.
  It includes a non-profit public insurance option designed to increase 
competition and lower prices.
  It provides affordability credits to lower-income Americans to help 
them pay for coverage.
  It modernizes and strengthens Medicare, ensuring the program's 
continued solvency and eliminating the prescription ``donut-hole.''
  And, very importantly, it is budget neutral.
  When I return to my constituents in California, I'll be proud to tell 
them that with this bill: Employer-based health coverage will improve 
for 461,000 men, women and children who live in my District; 84,000 
households in my District will receive affordability credits to help 
them pay for coverage they otherwise couldn't afford; 9,500 of the 
seniors in my District will no longer fall victim to the prescription 
drug ``donut-hole''; 17,100 small businesses in my District will be 
able to obtain affordable healthcare coverage; and that 15,400 small 
businesses will qualify for tax credits that will help reduce their 
health insurance costs.
  I'm also proud that I joined with Senator Kennedy to author H.R. 
3962, to create an FDA pathway for the approval of biosimilar drugs.
  Biotechnology is a complex and emerging field that can harness the 
power to cure cancer, AIDS, and diabetes, and prevent the onset of 
deadly and debilitating diseases such as Alzheimer's, heart disease, 
Parkinson's, multiple sclerosis and arthritis.
  My amendment will save the government $6 billion over the next ten 
years while continuing to foster innovation and new advancements.
  After President Obama signs this bill, millions of Americans who 
today have no health insurance will have it. Patients who are now 
denied coverage because of a pre-existing condition will no longer be 
shut out of the system. Millions more seniors will be able to afford 
their medications, and the average American family will pay less for 
their health coverage.
  Most importantly, we will be keeping our promise to the American 
people that they will have affordable health insurance which they 
cannot lose or have taken away from them if they become ill.
  I look forward to passing this landmark piece of legislation and 
seeing it signed into law by the President.
  Mr. ISRAEL. Mr. Speaker, I rise in support of the Affordable Health 
Care for America Act. I join the American Cancer Society, the American 
Medical Association, the American Nurses Association, Consumers Union, 
AARP, and many other organizations in the strong belief that this bill 
will bring financial relief to middle class families and businesses who 
have faced skyrocketing costs for health care.
  In the past months, I have listened carefully to the families and 
businesses I represent on Long Island. I held many public forums on 
health care; visited businesses facing double digit premium increases; 
met with physicians and toured hospitals; invited protesters into my 
office to hear their concerns; convened a tele-town hall that attracted 
5,000 senior citizens; hosted another tele-town hall meeting with 
nearly 11,000 people; organized a live town hall meeting at Suffolk 
Community College with 500 people; made hundreds of personal phone 
calls to constituents; and much more.
  People with strong opinions on opposite sides of this issue have 
insisted that I listen to them, believing that they represent a 
majority of our community. And at the end of the day, I believe 
strongly that we can no longer do business as usual. In the past 10 
years, Long Islanders have seen their health insurance premiums 
increase 80 percent. And if we do nothing, the average Long Islanders' 
health costs will increase $1,800 every year.
  Employer-sponsored health insurance premiums have increased 80 
percent in 10 years for Long Island businesses. As a result, more 
companies are forced to cut payroll, trim raises, or increase employee 
contributions. Some have told me if this continues, they will have to 
begin considering offering no health insurance.
  And almost every week, my office in Hauppauge receives complaints 
from neighbors who were denied insurance coverage due to preexisting 
conditions. They complain about ``sticker shock'' when they open their 
insurance company statement and learn that they'll have to pay for a 
greater share of services they assumed were covered.
  In a region with unacceptably high property taxes and energy costs, 
we simply cannot afford to allow health care to continue skyrocketing.
  The original bill did contain provisions that concerned me. As a 
result of my town meetings and other visits, I was able to help improve 
the bill.
  For example:
  Many Long Islanders complained that the original family income 
trigger for the surtax that will fund nearly half of this bill was too 
low. I successfully fought to raise the trigger to $1 million per 
family. As a result, no Long Island family with earnings less than $1 
million will see a surtax to pay for this bill.
  I worked to increase the trigger for small business health care from 
$250,000 to $500,000 in payroll.
  Many seniors in Medicare Part D prescription drug plans asked for 
faster relief from the so called ``donut hole.'' In 2010, they will 
receive an immediate $500 expanded benefit. That will assist 8,000 
seniors in our district alone.
  To lower drug costs, I fought to include a provision allowing the 
Department of Health and Human Services to negotiate volume discounts 
with big drug companies, just like the VA does.
  I sought to increase funding for the Family Caregiver Support program 
to help Americans who take care of their parents or grandparents.
  Some argued that insurance should be sold across State lines. This 
bill would allow companies to sell plans across State lines where 
States joined together to form interstate compacts to allow it.
  Before accessing the newly created Health Insurance Exchange, one's 
citizenship and immigration status will be verified by the Department 
of Homeland Security.
  Mr. Speaker, I have heard some insist that this bill represents a 
government takeover of health care. It is simply not true. All the bill 
does is give Long Islanders the choice to enter into a competitive 
Health Insurance Exchange to shop for a health insurance plan--just 
like every Member of Congress. There, private companies will compete 
for one's business. Among those private businesses will be a ``public 
option'' which must be self-sufficient and funded from premiums paid by 
its enrollees. That option will not need to worry about dividends or 
profits, CEO salaries or expensive marketing campaigns. It will compete 
against the private plans: just like public colleges compete against 
private colleges, just like ExpressMail competes against FedEx, just 
like Perrier competes against the Suffolk County Water Authority. I 
haven't heard anyone call the water they drink from their faucets 
``socialist water''. And I've not heard any reasonable person call 
Medicare socialized health care. The reason the public option is so 
vital is that its lower costs will incentivize insurance companies who 
have doubled their premiums to be more price sensitive in order to 
attract customers.
  Finally, Mr. Speaker, a special word for those who have demanded that 
I ``listen to them.'' We tend to see the world through our own eyes, 
leaving very little room for what may be outside our vision. People on 
polar

[[Page 27524]]

opposites of this issue have understandably demanded that I ``listen to 
them.'' Both claim to represent a majority of Long Islanders. I don't 
pay much attention to polls, Mr. Speaker, but a recent poll in Newsday 
indicated that 70 percent of Long Islanders support the public option. 
I will say that after that poll, some of the same people who demanded I 
listen to the majority told me the majority doesn't know what it's 
talking about so I should ignore it.
  I made a final judgment by listening carefully to everyone. I fought 
and delivered improvements in this bill. Is it perfect? No. Government 
can never be perfect, and I'll continue to demand that it be more 
competent. But this bill, for the first time, will give Americans more 
choice and control over a virtual health insurance monopoly and will 
finally end the days when someone who has faithfully paid their 
premiums from hearing that their diabetes, their cancer, their 
children's autism, are no longer covered.
  Mr. SCHOCK. Mr. Speaker, this past Monday night I decided I could 
better serve the citizens of the 18th district of Illinois by hosting a 
town hall meeting to listen to their thoughts and concerns with the 
Speaker's health care proposal, rather than rush back to Washington to 
vote on a resolution honoring man's best friend.
  As I participated in a town hall in Washington, Illinois with more 
than 1,000 people in attendance, I heard a reoccurring theme of 
concern, outrage, disbelief, frustration and fear for what Speaker 
Pelosi's health care proposal could mean.
  The final question of the night came from a young man named Joshua. 
In a room surrounded by those three or four times his age, young Joshua 
had the courage to ask me the difficult question if I supported what 
President Obama wants to do with Healthcare.
  I told Joshua that I've spent my first 9 months in office trying to 
figure out exactly what the President was actually trying to do with 
health care. It is this precise confusion of goals, conflicting 
messages and lack of communication from the Majority which has all 
Americans still trying to figure out exactly what the President and the 
Speaker are trying to do.
  Unfortunately, we've finally learned what they want to do. Tonight, 
under the cover of darkness, the majority finally passed a health care 
plan that will raise taxes, raise health care costs, add to our 
national debt, and hurt America's seniors, families and small 
businesses. Over half those covered in the bill are done so by 
expanding entitlements instead of helping them afford insurance. This 
only exacerbates insurance premiums for ordinary Americans and 
dramatically increases our nation's debt.
  The bill tonight was about expanding the size of government and 
leading us down the road to a no-choice government-run healthcare 
system. Instead of working across party lines to pass bipartisan 
reform, Speaker Pelosi has decided to let the votes against this 
massive entitlement expansion be the only true thing bipartisan about 
it.
  Mr. THOMPSON of Mississippi. Mr. Speaker, I and others have spoken at 
length on the ways that this bill will improve health care for all of 
our constituents. Another significant benefit of this legislation which 
has not received as much attention will be the creation of new high-
paying jobs in this country. Let me repeat that for some of my friends 
on the other side of the aisle, this bill will create high-paying, 
high-quality jobs in health care delivery, technology, and research in 
the United States.
  First, this bill will create enormous demand for health care workers, 
especially in the area of primary care. Insuring millions of Americans 
in this country who currently have no insurance will allow them to see 
primary care providers and receive the wellness and preventive care 
they have been denied for too long. This influx of new patients will 
need doctors, nurses and technicians for their care, while reducing 
overall health care costs because they will not need much more 
expensive hospitalizations. I support channeling resources that for too 
long have been used to treat people once they become sick into jobs and 
services that will prevent people from getting sick in the first place.
  Second, this bill will continue the efforts we began in the stimulus 
package to deploy new health information technologies that better 
manage both the quality of care patients receive and the cost at which 
they receive it. New health care exchanges and new demands on the 
health system to provide high-quality and cost-effective health care 
will create new opportunities and markets for our brightest minds in 
technology. They will be incentivized to create and develop products 
that will be a win/win for Americans: high-quality health care at an 
affordable price.
  Third, this bill will create high-quality research opportunities in 
this country. The Energy and Commerce Committee enacted a framework for 
allowing biosimilar competition in this country. This new class of 
medicines will help lower costs and bring competition to one area that 
is key to the future of our health care system. Biotechnology is on the 
cutting edge of efforts to reduce costly invasive procedures and allow 
our constituents to live healthier and more productive lives. The 
creation of this new class of medicines comes with requirements for new 
clinical research and testing, especially in the area of whether a new 
biosimilar can be interchangeable with an innovator's product. This 
research will create high-quality and high-paying jobs and it is 
imperative that we keep this research and these jobs in this country. 
We cannot allow these research opportunities to leave the United States 
and we must ensure that these new medicines are safe. I intend to work 
with the Secretary of HHS and the Commissioner of the FDA to ensure 
that the testing and research on these biosimilars occur in this 
country to make certain that it is done properly and safely and to 
benefit our economy.
  Mr. Speaker, this bill is an investment and an exciting opportunity 
to create the kind of jobs we so desperately need in this United States 
while at the same time improving the lives of all Americans. This bill 
will improve health care, create jobs, and grow our economy.
  Mr. LANGEVIN. Mr. Speaker, I rise in strong support of H.R. 3962, the 
Affordable Health Care for America Act. Congress has made unprecedented 
strides this year in the fight to reform our nation's health insurance 
system and provide coverage to all Americans, and today's vote 
represents a historic culmination of these vast, collaborative efforts. 
This transformative bill offers real solutions for Rhode Islanders by 
providing better access to affordable, quality health care coverage and 
finally puts America back on the path to an efficient and sustainable 
health care system.
  This summer, I traveled across the district to meet with Rhode 
Islanders and discuss health reform. I met with constituents who had 
health insurance all their lives, but then lost it when they were 
diagnosed with cancer. I met with small business owners who provided 
coverage for their employees for decades, but were forced to 
discontinue it when they could no longer keep up with skyrocketing 
costs. And I met with parents who were desperate to protect their 
childrens' health, but feared they would soon run up against lifetime 
insurance caps.
  All of these stories conveyed the same message--health care costs in 
the United States are rising at an unsustainable rate, and they are 
placing a huge burden on Rhode Island families, employers and health 
care providers. This year alone, over 13,000 Rhode Islanders lost their 
insurance coverage due to rising unemployment. And those who still have 
coverage are struggling with rising premiums, co-pays and crushing 
medical debt. Meanwhile, yearly double-digit premium increases are 
forcing businesses to choose between keeping their employees' health 
coverage and keeping their employees.
  As a longtime advocate of universal health care, I made a promise to 
my constituents to change the status quo of health care in America. The 
time for inaction is over--we must join together to pass this bill.
  H.R. 3962 will institute the changes we need to provide more security 
and stability to Americans who have health insurance, guarantee 
insurance to the millions who don't, and lower health care costs for 
our families, businesses and the government.
  This legislation builds on the strengths of our current employer-
based system by encouraging businesses who offer their own coverage to 
continue doing so. Americans who don't have coverage through their 
employer will be able to shop for their choice of a health plan through 
a new ``health insurance exchange,'' modeled after the tried and true 
Federal Employees Health Benefits Program, which successfully provides 
coverage for over 9 million federal employees, retirees and their 
dependents.
  Unlike the limited options that are available to most consumers 
today, the exchange will provide a more convenient, transparent and 
affordable way to choose among a variety of health plans that meets 
individual needs. Americans who cannot afford to purchase coverage 
within the exchange will receive financial assistance to ensure that 
they can obtain comprehensive coverage. Additionally, small businesses 
will receive tax credits that will make it more affordable to offer 
insurance to their employees.
  I am also pleased that this bill encourages competition by ensuring 
that Americans will have the ability to choose a public plan 
alternative. Unlike private insurance carriers, the public option will 
not be obligated by big profits for shareholders or large salaries for 
CEOs.

[[Page 27525]]

And while it represents just one option for the consumer and one 
component of health care reform, it will serve as an important tool to 
increase choice and competition and lower overall insurance costs.
  Included in this proposal are a number of important health consumer 
protections. It will finally end insurance discrimination against 
people with pre-existing conditions and prevent insurance companies 
from imposing lifetime limits or dropping coverage when people are sick 
and need it most. It will cap out-of-pocket expenses so people don't go 
broke when they get sick; eliminate extra charges for preventive care 
like mammograms and diabetes tests; and protect Medicare for seniors 
while working to eliminate the ``donut-hole'' gap in coverage for 
prescription drugs. It will also require that insurers reinvest at 
least 85 percent of their premiums back into health coverage. This will 
limit the amount of money spent on advertising, underwriting, overhead 
and profits that do nothing but reduce health benefits for patients.
  Improving access to coverage will also require investments in our 
health care workforce. Our system is strained by a lack of nurses and 
primary care physicians, particularly in underserved areas. That is why 
our bill contains important workforce development initiatives like new 
scholarships and loan repayment programs, grant programs for primary 
care training and immediate financial support for community health 
centers. This will strengthen the number of nurses, doctors and other 
health care professionals necessary to meet the increased demand for 
services.
  This bill also makes historic changes to our antitrust laws by 
removing exemption enjoyed by insurance companies so that they are no 
longer shielded from liability for price fixing or dominating their 
market--all of which reduce competition and increase prices for 
consumers. It establishes new grant programs designed to encourage 
states to implement alternatives to traditional medical malpractice 
litigation with the goal of reducing frivolous lawsuits while allowing 
legitimate cases to be heard. This bill also has my strong support 
because every portion will be completely paid for, and it will reduce 
the deficit by $109 billion over the next ten years.
  Mr. Speaker, I believe it is incumbent on us as policymakers to offer 
a new vision for health care in America--one that contains costs, 
improves quality, increases efficiency, promotes wellness, puts health 
care decisions back in the hands of patients and doctors, and 
guarantees coverage as a right to our citizens.
  Every American deserves the promise of quality, affordable health 
care. I urge my colleagues to join me in fulfilling that promise today, 
and support the Affordable Health Care for America Act.
  Ms. EDWARDS of Maryland. Mr. Speaker, I strongly support H.R. 3962, 
the Affordable Health Care for America Act because it eliminates the 
discriminatory insurance industry practice of charging women higher 
premium rates than male customers for the same insurance benefits. This 
practice, known as ``gender rating,'' leaves women burdened by higher 
insurance costs. In fact, women are charged 25-50 percent more than men 
for comparable insurance benefits. For decades, insurance underwriters 
have tried to justify this disparity by asserting that women use more 
health care, especially during child-bearing years. This claim is 
contradicted by the reality that many women are denied insurance 
coverage for maternity care and even denied coverage based on a history 
of prior pregnancies. Further, female nonsmokers pay more for health 
insurance than men who smoke. In a recent study, more than half of 
women (compared to 39 percent of men) reported delaying needed medical 
care due to cost. Gender rating is prohibited in the individual market 
in 10 States (Maine, Massachusetts, Montana, Minnesota, New Hampshire, 
New Jersey, New York, North Dakota, Oregon, and Washington). Two States 
have ``rate bands'' that allow 20 percent variation in charges (Vermont 
and New Mexico). Twelve States ban gender rating in the small group 
market, including my home State of Maryland (as well as California, 
Colorado, Minnesota, Michigan, Montana, Maine, Maryland, Massachusetts, 
New Hampshire, New York, Oregon, and Washington). H.R. 3962 ends the 
discriminatory practice of gender rating in all States and ensures that 
women and men are charged equitable prices for premiums.
  As a life-long advocate of women's rights and a domestic violence 
prevention advocate, I support this ban on gender rating and support 
equal access to the insurance market for women.


                    Amendment Offered by Mr. Stupak

  Mr. STUPAK. Mr. Speaker, I have an amendment at the desk.
  The SPEAKER pro tempore. The Clerk will designate the amendment.
  The text of the amendment is as follows:

       Part C amendment printed in House Report 111-330 offered by 
     Mr. Stupak:
       Page 97, strike line 13 and all that follows through page 
     98, line 7.
       Page 110, strike lines 1 through 7.
       Page 114, line 21, strike ``consistent with subsection (e) 
     of such section''.
       Page 118, line 21, strike ``(including subsection (e))''.
       Page 154, after line 18, insert the following new section 
     (and conform the table of contents of division A 
     accordingly):

     SEC. 265. LIMITATION ON ABORTION FUNDING.

       (a) In General.--No funds authorized or appropriated by 
     this Act (or an amendment made by this Act) may be used to 
     pay for any abortion or to cover any part of the costs of any 
     health plan that includes coverage of abortion, except in the 
     case where a woman suffers from a physical disorder, physical 
     injury, or physical illness that would, as certified by a 
     physician, place the woman in danger of death unless an 
     abortion is performed, including a life-endangering physical 
     condition caused by or arising from the pregnancy itself, or 
     unless the pregnancy is the result of an act of rape or 
     incest.
       (b) Option To Purchase Separate Supplemental Coverage or 
     Plan.--Nothing in this section shall be construed as 
     prohibiting any nonfederal entity (including an individual or 
     a State or local government) from purchasing separate 
     supplemental coverage for abortions for which funding is 
     prohibited under this section, or a plan that includes such 
     abortions, so long as--
       (1) such coverage or plan is paid for entirely using only 
     funds not authorized or appropriated by this Act; and
       (2) such coverage or plan is not purchased using--
       (A) individual premium payments required for a Exchange-
     participating health benefits plan towards which an 
     affordability credit is applied; or
       (B) other nonfederal funds required to receive a federal 
     payment, including a State's or locality's contribution of 
     Medicaid matching funds.
       (c) Option To Offer Separate Supplemental Coverage or 
     Plan.--Notwithstanding section 303(b), nothing in this 
     section shall restrict any nonfederal QHBP offering entity 
     from offering separate supplemental coverage for abortions 
     for which funding is prohibited under this section, or a plan 
     that includes such abortions, so long as--
       (1) premiums for such separate supplemental coverage or 
     plan are paid for entirely with funds not authorized or 
     appropriated by this Act;
       (2) administrative costs and all services offered through 
     such supplemental coverage or plan are paid for using only 
     premiums collected for such coverage or plan; and
       (3) any nonfederal QHBP offering entity that offers an 
     Exchange-participating health benefits plan that includes 
     coverage for abortions for which funding is prohibited under 
     this section also offers an Exchange-participating health 
     benefits plan that is identical in every respect except that 
     it does not cover abortions for which funding is prohibited 
     under this section.
       Page 171, strike line 5 and all that follows through page 
     172, line 8.
       Page 182, line 22, strike ``willingness or''.
       Page 246, strike lines 11 through 14.

  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
gentleman from Michigan (Mr. Stupak) and a Member opposed each will 
control 10 minutes.
  The Chair recognizes the gentleman from Michigan.
  Mr. STUPAK. Mr. Speaker, I ask unanimous consent that 5 of the 10 
minutes granted to our side be controlled by the gentleman from 
Pennsylvania (Mr. Pitts).
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from Michigan?
  There was no objection.
  Mr. STUPAK. Mr. Speaker, our amendment does one very simple thing: It 
applies the Hyde amendment, which bars Federal funding for abortion 
except in the case of rape, incest, or life of the mother to the health 
care reform bill. The Hyde amendment has been law in Federal funding of 
abortion since 1977 and applies to all other federally funded health 
care programs, including SCHIP, Medicare, Medicaid, Indian Health 
Services, veterans health, military health care programs, and the 
Federal Employees Health Benefits Program.
  More specifically, our amendment applies the Hyde amendment to the 
public health insurance option and private policies purchased using 
affordability credits. I am not writing a new Federal abortion policy. 
The Hyde amendment already prohibits Federal funding of abortion and 
the use of Federal dollars to pay for health care policies that cover 
abortion. This policy

[[Page 27526]]

currently applies to the 8 million Americans, including Members of 
Congress, covered under the Federal Employees Health Benefits Program, 
and should apply in this bill.
  The amendment has no impact on those individuals with private 
insurance who do not receive affordability credits and in no way 
prohibits any individual from purchasing a supplemental abortion 
coverage policy. Health insurance companies can still offer policies in 
the exchange that cover abortion; they just can't sell those policies 
to individuals receiving affordability credits.
  I wish to thank Speaker Pelosi for her commitment to trying to reach 
an agreement between all sides late last night. Unfortunately, at the 
last minute the deal fell apart. The Speaker then took the only 
appropriate action remaining, which was to allow a vote on the floor.
  So we are asking Members to maintain current law and vote ``no'' on 
public funding for abortion. Let me also reassure my colleagues, both 
Democrats and Republicans, I did not buck my party. I did not buck my 
party leadership to trade a vote for this amendment. I did it based on 
principle.
  This bill, with the Capps language, is the most direct assault on the 
Hyde language we have had since 1997. So I ask my colleagues, Democrats 
and Republicans alike, let us stand together on the principle of no 
public funding for abortion, no public funding for insurance policies 
that pay for abortion. Stand with us, protect our role, and let's keep 
current law.
  I reserve the balance of my time.
  Ms. DeGETTE. Mr. Speaker, I rise to claim the time in opposition to 
the Stupak-Pitts amendment.
  The SPEAKER pro tempore. The gentlewoman from Colorado is recognized 
for 10 minutes.
  Ms. DeGETTE. I yield myself 3 minutes, Mr. Speaker.
  Mr. Speaker, to say that this amendment is a wolf in sheep's clothing 
would be the understatement of a lifetime. The proponents say it simply 
extends the Hyde amendment, just a clarification of current law. 
Nothing could be further from the truth.
  If enacted, this amendment will be the greatest restriction of a 
woman's right to choose to pass in our careers.

                              {time}  1945

  Here is why: The Hyde amendment states that no Federal funds shall be 
used for abortions. This has been contained in our annual 
appropriations bills for many years.
  In the Energy and Commerce Committee, the pro-choice and some pro-
life Democrats came together and compromised and we said no Federal 
funds in this bill will be used for abortions, the Capps amendment. 
This bill does not spend one Federal dollar on abortions.
  This Stupak-Pitts amendment goes much further. It says that as part 
of their basic coverage, the public option cannot offer abortions to 
anyone, even those purchasing the policies with 100 percent private 
money. The amendment further says that anyone who purchases insurance 
in the exchange and who receives premium assistance cannot get 
insurance coverage for a legal medical procedure even with the portion 
of their premium that is their own private money.
  Well, the proponents say women can just purchase supplemental 
insurance for abortions. This very notion is offensive to women. No one 
thinks that women will have an unplanned pregnancy or a planned 
pregnancy that goes terribly wrong. Would we expect to have people buy 
supplemental insurance for cancer treatment just in case maybe they 
might get sick? Like it or not, this is a legal medical procedure, and 
we should respect those who need to make this very personal decision.
  Once again, the base bill contains language that preserves the Hyde 
amendment. Let's keep our eyes on the goal here, providing safe medical 
treatment for 36 million Americans. Let's not sacrifice reproductive 
rights today in pursuance of that noble goal.
  I reserve the balance of my time.
  Mr. PITTS. Mr. Speaker, I yield myself 1\1/4\ minutes.
  I rise in support of this bipartisan amendment.
  Polls have repeatedly shown that the public does not support Federal 
funding of abortion, yet that is exactly what is in this bill. Current 
law actually prevents any Federal health care plan from paying for 
abortion. It also prevents taxpayer subsidies from flowing to benefit 
packages that include abortion. However, the Capps amendment included 
in this legislation would have the opposite effect.
  Under this bill, funds will flow from premium payments and 
affordability credits into the U.S. Treasury account, and that account 
will then reimburse for abortion services. Every dollar in the public 
option is a Federal dollar. Let me be clear, if the government plan 
covers abortion, that amounts to Federal funding for abortion. It's 
that simple. Our amendment would maintain the principles of the Hyde 
amendment, something that the large majority of Americans support.
  I urge my colleagues to stand with the majority of the American 
people, to oppose establishing a Federal Government program that will 
directly fund abortion on demand, to keep the government out of the 
business of promoting abortion as health care, and support this 
amendment.
  I reserve the balance of my time.
  Ms. DeGETTE. I yield 1 minute to the distinguished gentlelady from 
Connecticut (Ms. DeLauro).
  Ms. DeLAURO. This amendment undermines the thoughtfully crafted and 
balanced language in the bill that already prohibits Federal funds from 
being used to pay for abortion. It attempts an unprecedented overreach 
of women's basic rights and freedoms in this country.
  Abortion is a matter of conscience on both sides of the debate, and 
it goes to the very heart of our belief as citizens and as legislators. 
This amendment takes away that same freedom of conscience from 
America's women. It prohibits them from access to an abortion even if 
they pay for it with their own money. It invades women's personal 
decisions, discriminates against working women, and, put simply, 
violates the law of the land.
  Access to quality, affordable health care coverage is a question of 
life or death for millions of Americans. We should not be injecting 
this divisive and polarizing issue into our debate.
  The best vote for life we could make today would be to pass the 
critical reforms American families have asked for and desperately need.
  I urge my colleagues to oppose this amendment.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair would remind Members to please 
heed the gavel.
  Mr. STUPAK. Mr. Speaker, I yield 45 seconds to Mrs. Dahlkemper from 
Pennsylvania to speak on the bill. She has been a stalwart on this 
issue, and I appreciate her support on this issue.
  Mrs. DAHLKEMPER. Mr. Speaker, I want to thank Congressman Stupak.
  I rise today to ask my colleagues to support the Stupak-Ellsworth-
Pitts-Kaptur-Dahlkemper-Lipinski-Smith amendment which will keep in 
place current Federal law on abortion funding in H.R. 3962, the 
Affordable Health Care for America Act.
  Mr. Speaker, our amendment does not change current law regarding 
abortion. It does not outlaw abortion. It does not prohibit women from 
making a choice to which they are entitled under the law. What this 
amendment does do is make the House's health care reform legislation 
consistent with all other Federal health care programs, including 
Medicaid, Medicare, SCHIP, and veterans care. It prohibits Federal 
funding for abortions consistent with legislation that has been in 
place since the 1970s.
  Ms. DeGETTE. I am now delighted to yield 1 minute to the gentlelady 
from California (Mrs. Capps).
  Mrs. CAPPS. Mr. Speaker, I rise in strong opposition to this 
amendment.
  Contrary to what its sponsors and their supporters say, the 
underlying bill does prohibit Federal funding for abortion. It is 
written clearly and plainly on page 246, line 11, ``prohibition of use 
of public funds for abortion coverage.'' But apparently that isn't good 
enough for people whose goal really is to strip women of their right to

[[Page 27527]]

choose altogether despite purporting to just want to maintain the 
status quo. So instead we have this amendment which restricts a woman's 
right to access a legal medical procedure in this country.
  It is ironic, actually, because most of the people who support the 
amendment claim to oppose government interference in health care, yet 
this amendment is government interference and a decision that should be 
made between a woman and her physician.
  If this amendment passes, it will be the only language in the entire 
legislation that actually restricts coverage of a legal medical 
procedure. Not one other legal medical procedure is singled out in this 
legislation for rationing.
  I urge my colleagues to vote ``no'' on this devastating amendment.
  Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentleman from 
Indiana, Chairman Mike Pence.
  Mr. PENCE. Mr. Speaker, I rise in support of this amendment, though 
it will not change my opposition to the Pelosi health care bill. I am 
grateful this amendment has been brought to the floor, and I wish to 
commend Mr. Pitts and Mr. Stupak for their principled leadership.
  Ending an innocent human life is morally wrong, but it's also morally 
wrong to take the taxpayer dollars of millions of Americans and use 
them to provide for a procedure that they find morally offensive. In 
the Congress of the United States, we have a responsibility to respect 
the moral beliefs of the majority of the American people.
  I urge my colleagues to prevent Federal dollars from funding 
abortions. Take a stand for life, support the Stupak-Pitts amendment, 
and vote ``no'' on Pelosi health care.
  Ms. DeGETTE. I yield 1 minute to the distinguished gentlelady from 
New York (Mrs. Lowey).
  Mrs. LOWEY. I rise in strong opposition to this amendment. This is a 
disappointing distraction from the bill before us.
  Under current law, no taxpayer funds can be used to cover abortion. 
While I believe abortion should be legal and safe, I have worked for 
years with colleagues on both sides of this issue to also make this 
procedure rare. If we want to reduce abortions, we should provide women 
health coverage for reproductive care, contraceptives to prevent 
unintended pregnancies, and prenatal care to ensure healthy 
pregnancies.
  This amendment threatens the rights and health of women to seek a 
legal procedure covered by the premiums they will pay out from their 
own pockets. The underlying bill would uphold current law which states 
that no Federal funds can support abortion. Therefore, I urge my 
colleagues to oppose this unnecessary and reprehensible amendment.
  Mr. STUPAK. Mr. Speaker, may I inquire as to how much time we have 
remaining?
  The SPEAKER pro tempore. The gentleman from Michigan has 2\1/4\ 
minutes remaining. The gentlewoman from Colorado has 4\1/2\ minutes 
remaining. The gentleman from Pennsylvania has 3\1/2\ minutes 
remaining.
  Mr. STUPAK. Mr. Speaker, I continue to reserve.
  Ms. DeGETTE. Mr. Speaker, I reserve.
  Mr. PITTS. Mr. Speaker, at this time, I yield 30 seconds to the 
gentlelady from Washington, Vice Chairwoman Cathy McMorris Rodgers.
  Mrs. McMORRIS RODGERS. Mr. Speaker, many have stood before me from 
both sides of the aisle to ensure that Federal taxpayer dollars do not 
fund abortion, whether it's Medicaid, whether it's the Federal 
Government's own health program. Today, I stand to ensure that this 
policy is included in the health care bill that is being rammed through 
this Congress.
  If we are talking about health care reform for women and children, 
then protection for children should start at the moment their life 
begins. Two-thirds of women recently polled representing all parties, 
races, and marital statuses object to government funding of abortion.
  I urge my colleagues to support this amendment.
  Mr. STUPAK. Mr. Speaker, I yield 1 minute to Mr. Ellsworth from 
Indiana, who has been a champion on this issue and has worked hard to 
get this amendment to where we are here today.
  Mr. ELLSWORTH. Thank you, Mr. Stupak.
  Mr. Speaker, I rise today to urge the passage of this vital 
amendment.
  Since this debate started, my goal has been to ensure Federal 
taxpayer dollars are not used to pay for abortions and to provide 
Americans with pro-life options on this exchange. I have been proud to 
work with Mr. Stupak and all my colleagues and the Catholic Bishops to 
make the goal a reality.
  Getting to this point has not been very easy, but today we're on the 
brink of passing health care reform that honors and respects life at 
every stage, including the unborn. If this amendment passes today, I 
will support this bill.
  It is time to fix what's broken in our health care system and begin 
to fulfill the promises we've made to Americans that we represent. 
That's why I urge Members on both sides of the aisle to vote for this 
amendment.
  Ms. DeGETTE. Mr. Speaker, I am delighted to yield 1 minute to the 
gentlelady from California (Ms. Lee).
  Ms. LEE of California. Mr. Speaker, this amendment inserts the 
Federal Government further directly into the medical decisions that a 
woman makes with her doctor.
  As a person of faith who was raised in the Catholic Church, I have 
the deepest respect for Mr. Stupak and Mr. Pitts. I know personally the 
moral dilemmas women face in making personal decisions about abortion, 
but I'll tell you one thing, I remember the days of back alley 
abortions, and this amendment takes us one step back to those dark 
days.
  This amendment goes way beyond the Hyde amendment that denies Federal 
funds for abortion and attempts to dictate to women how to spend their 
own money. It is simply outrageous. It is outrageous.
  It further places the religious views, mind you, of some into our 
public policy. Again, we're a democracy; we're not a theocracy. The 
separation of church and State requires us as legislators to never 
cross this line and it allows personal religious views to be personal. 
We should not, as Members of Congress, compromise this separation. And 
low-income women especially will be hurt by this amendment. Reject it.
  Mr. PITTS. Mr. Speaker, at this time, I yield 30 seconds to the 
ranking member of the Budget Committee, the gentleman from Wisconsin, 
Paul Ryan.
  Mr. RYAN of Wisconsin. Mr. Speaker, this is perhaps the worst bill I 
have seen come to the floor in my 11 years of serving in Congress, and 
what would make this bill worse is if we break with the long-standing 
law of preventing abortions from being funded with taxpayer dollars.
  For those of us who support the protection of and the sanctity of 
life, the only vote, the right vote, the vote to keep a clean 
conscience is a ``yes'' vote for the Stupak amendment.
  Ms. DeGETTE. Mr. Speaker, I am now pleased to yield 1 minute to the 
distinguished gentleman from New York (Mr. Nadler).
  Mr. NADLER of New York. Mr. Speaker, I rise in opposition to the 
Stupak amendment.
  Despite significant efforts made by the underlying bill to level the 
playing field for women and to end discrimination against them in the 
health insurance market, this amendment adds a new discriminatory 
measure against women. Under this proposal, if a woman is of low or 
moderate income and receives tax credits to help her to afford the 
premiums for a health insurance plan she purchases on the exchange, she 
cannot choose a plan that covers abortion services. And if she chooses 
the public option, she cannot receive abortion coverage at all, even if 
she receives no help of any kind and pays for the plan entirely by 
herself.
  The provision inserted in the underlying bill by our colleague, 
Representative Capps, extends the Hyde amendment in current law by 
ensuring that no Federal dollars can be used to fund abortions. That 
should be sufficient.
  This is a bill to extend health care to all Americans. It should not 
be used as

[[Page 27528]]

a political football to try to change existing laws regarding abortion 
coverage.
  Mr. Speaker, I reiterate my opposition to this discriminatory 
amendment and ask my colleagues to vote ``no.''
  Mr. Speaker, I rise in opposition to the Stupak amendment.
  Despite significant efforts made by the underlying bill to level the 
playing field for women and end discrimination against them in the 
health insurance market, this amendment adds a new discriminatory 
measure against women. Under the Stupak proposal, if a woman is of low- 
or moderate income and receives tax credits to help her afford the 
premiums for a health plan she purchases through the Exchange, she 
cannot choose a plan that covers abortion services. And if a woman 
chooses the public option, she cannot receive abortion coverage--even 
if she receives no help of any kind and pays for the plan entirely by 
herself.
  The Stupak amendment says to women--if you think you might have an 
unintended pregnancy, you should purchase separate insurance. Put 
another way, this amendment requires women to plan that they will 
encounter an unplanned pregnancy. This defies logic and is absurd.
  The compromise provision inserted in the underlying bill by our 
colleague, Representative Capps, extends the Hyde Amendment in current 
law by ensuring that no federal dollars can be used to fund abortions. 
That should be sufficient.
  This is a bill to extend health care to all Americans. It should not 
be used as a political football to change existing law regarding 
abortion coverage.
  Mr. Speaker, I reiterate my opposition to this discriminatory 
amendment and ask my colleagues to vote ``no.''

                              {time}  2000

  Mr. STUPAK. Mr. Speaker, I continue to reserve the balance of my 
time.
  Ms. DeGETTE. Mr. Speaker, I continue to reserve the balance of my 
time.
  Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentlewoman from 
Minnesota, Michele Bachmann.
  Mrs. BACHMANN. Mr. Speaker, it all begins with life and with 
protecting the most vulnerable among us, the unborn. Life is the 
watershed issue of our generation. How can one claim to call the 
destruction of innocent human life ``health care''?
  Orwellian statements aside, it is the duty of government to preserve 
and protect human life. If we do nothing else tonight, let's choose 
life.
  Ms. DeGETTE. I inquire of the Speaker as to the time remaining.
  The SPEAKER pro tempore. The gentlewoman has 2\1/2\ minutes. The 
gentleman from Michigan has 1\1/4\ minutes remaining. The gentleman 
from Pennsylvania has 2 minutes remaining.
  Ms. DeGETTE. Mr. Speaker, I yield 30 seconds to the distinguished 
gentleman from Illinois (Mr. Quigley).
  Mr. QUIGLEY. Mr. Speaker, the health care bill we are considering 
today makes a strong statement that everyone in this country deserves 
access to health care.
  For over 8 months, this body has strived to overcome the health care 
inequalities in our country, but this amendment disrupts that sense of 
equality. This amendment says that only women who can afford insurance 
deserve access to reproductive health care. This amendment says that 
women who need a little help paying for health care have to surrender 
their right to privacy.
  This amendment will serve only to hurt low-income women, and it will 
restrict their ability to access reproductive health care even with 
their own money. It is wrong and we should oppose it.
  Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentleman from 
Nebraska, Jeff Fortenberry.
  Mr. FORTENBERRY. Mr. Speaker, the vast majority of Americans oppose--
do not want--their government funding abortion.
  I want to thank Mr. Stupak and Mr. Pitts for this amendment to 
prohibit Federal funding for abortion in the guise of health care 
reform. Women deserve better.
  Last week, we heard a lot of talk about compromise. Well, Mr. 
Speaker, neither a child in an early phase of life nor an elderly 
person clinging to each breath in the waning days of this life should 
ever be subject to a compromise. I hope that, if House has learned 
anything from this debate, it is this: that we must first do no harm. 
It is not ours to decide who lives or who dies.
  Ms. DeGETTE. Mr. Speaker, I am now delighted to yield 30 seconds to 
the distinguished Chair of the Rules Committee and the co-Chair of the 
Congressional Pro-Choice Caucus, the gentlewoman from New York (Ms. 
Slaughter).
  Ms. SLAUGHTER. I thank the gentlewoman for yielding.
  Mr. Speaker, for over 30 years, we lived in this House in peaceful 
co-existence with the pros and cons getting together on the fact that 
the Hyde amendment said that no Federal money can be spent--the 
strongest conscience clause in the world--which is now being 
strengthened, by the way, in this bill. We on our side simply have the 
law.
  I am very concerned about this bill because, in my own case and in 
the cases of many of my colleagues, it means 30 or 40 years of our life 
is being canceled out with this amendment. After the things that we 
have fought for, we are driving now, I am afraid, young women and poor 
women who cannot afford to buy their own insurance policies out of 
their pockets back to the back alley. I dread to see that day.
  Mr. PITTS. Mr. Speaker, we are prepared to close on our side.
  Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to 
the gentlewoman from Wisconsin (Ms. Baldwin).
  Ms. BALDWIN. Mr. Speaker, I rise in opposition to this amendment.
  A journalist asked me a few years ago if I could point to one thing 
that has contributed the most to the empowerment of women in our 
society. In answer to that query, I might have pointed to the 19th 
Amendment to the Constitution giving women the right to vote, or Title 
VII of the Civil Rights Act of 1964, or laws mandating equal pay for 
equal work. But instead, I responded to that journalist that it is the 
array of legal choices a woman now has that make it possible for her to 
plan her family--to decide whether to have children, and to decide when 
to have children. We refer to this array of choices as ``reproductive 
freedom.''
  In the days before women were able to legally access contraception 
and abortion services, women often had to drop out of school, few could 
pursue careers in the professions, and too many women in desperate 
circumstances lost their lives from so-called back-alley abortions.
  In 1970 women made up a third of the workforce. Today for the first 
time in history, women make up half of the U.S. workforce. In 1970, ten 
women served in the House of Representatives. Today there are 76. In 
1970, the percentage of female medical students was 9.6 percent. This 
year, women are 48 percent of our Nation's medical students. In 1970, 
the percentage of women in law school was 8 percent. Today, 46.7 
percent of law students are female.
  These are just some of the changes in the role of women in American 
society that have occurred over the years during which women have 
secured the right to a full range of family planning options.
  The Stupak/Pitts amendment is an erosion of a woman's reproductive 
freedom. Access to abortion services in the United States is already 
severely limited. State laws mandating waiting periods, the lack of 
insurance coverage of abortion and the scarcity of clinics providing 
abortion services mean that the right to a safe and legal abortion for 
many women is already pretty hollow. If this amendment is adopted, a 
woman's right to choose will be further limited.
  I urge my colleagues to oppose this amendment.
  Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to 
the distinguished gentlewoman from New York (Mrs. Maloney).
  Mrs. MALONEY. Mr. Speaker, I rise in strong opposition to this 
amendment.
  Mr. Speaker, it is outrageous that even the historic bill to extend 
health coverage to 96 percent of Americans includes an abortion fight 
because of the anti-abortion movement.
  The Stupak amendment is a huge step backwards for American women.
  Mr. Speaker, I rise in strong opposition to the Stupak/Pitts 
amendment which plainly discriminates against women, puts women's 
health at risk, and marks an unprecedented

[[Page 27529]]

restriction on people who pay for their own health insurance.
  The commonsense Capps Compromise which was agreed to during debate in 
the Energy and Commerce Committee ensures that taxpayers will not be 
paying for abortion and reflects the status quo and current law.
  It prohibits federal funds from being used for abortion but still 
allows women to use their own money to buy the coverage they need.
  Despite this effort to address concerns raised by pro-life Members, 
Representatives Stupak and Pitts decided to further restrict women's 
access to care by offering their shortsighted, dangerous, and 
discriminatory amendment to H.R. 3962.
  The Stupak/Pitts amendment would make abortion coverage virtually 
inaccessible for most women in the new exchange.
  It does so by:
  (1) Banning abortion coverage in the exchange for women who receive 
subsidies, except by separate rider that they could only purchase with 
their own, private funds.
  (2) Making it highly unlikely that women buying insurance in the 
exchange with their own money could obtain abortion coverage.
  It is an outrage that at time when we are making historic changes--
expanding American's access to health care--a group of legislators are 
bonding together to deprive women of the very health care they both 
need and deserve.
  Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to 
the distinguished gentlewoman from Maryland (Ms. Edwards).
  Ms. EDWARDS of Maryland. Mr. Speaker, I rise in opposition to this 
amendment.
  Ms. DeGETTE. Mr. Speaker, I yield 1 minute to the distinguished 
gentlewoman from Illinois (Ms. Schakowsky).
  Ms. SCHAKOWSKY. No matter how many times it is said, our health 
reform bill does not allow one Federal dollar for abortions.
  This Stupak-Pitts amendment goes way beyond current law. It says a 
woman cannot purchase, using her own dollars, coverage that includes 
abortion services. Even middle class women who are using exclusively 
their own money will be prohibited from purchasing a plan including 
abortion coverage, and this is in every single public or private 
insurance plan in the new health care exchange. Her only option is to 
buy a separate insurance policy that covers an abortion, a ridiculous 
and unworkable approach since no woman plans an unplanned pregnancy.
  This amendment is a radical departure from current law, and it will 
result in millions of women losing the coverage they already have. Our 
bill is about lowering health care costs for millions of women and 
their families. It is not about further marginalizing women by forcing 
them to pay more for their care.
  This amendment is a disservice and an insult to millions of women 
throughout the country. I urge a ``no'' vote on this amendment.
  The SPEAKER pro tempore. The Chair will remind the gentlewoman from 
Colorado that she has the right to close.
  The gentleman from Michigan has 1\1/4\ minutes remaining. The 
gentleman from Pennsylvania has 1\1/2\ minutes remaining. The 
gentlewoman from Colorado has 30 seconds remaining.
  Mr. STUPAK. Mr. Speaker, I yield 15 seconds to the gentleman from 
Illinois (Mr. Lipinski) to state how current laws are maintained with 
the Stupak amendment.
  Mr. LIPINSKI. Mr. Speaker, I thank my colleagues, especially Mr. 
Stupak, for their perseverance as we work together on this amendment. 
Every year for over three decades, including this past July, we have 
approved the Hyde amendment.
  I ask my colleagues again tonight: do the same thing, and approve the 
Hyde amendment in this bill.
  Ms. DeGETTE. Mr. Speaker, I reserve the balance of my time.
  Mr. PITTS. Mr. Speaker, I yield to the gentleman from Texas (Mr. 
Gohmert) for a unanimous consent request.
  Mr. GOHMERT. Mr. Speaker, I rise in support of the wonderful work in 
the Stupak-Pitts amendment, addressing things like the money on page 
110 for abortions.
  Mr. PITTS. Mr. Speaker, I yield the balance of the time to the Chair 
of the Pro-Life Caucus in support of this bipartisan amendment, the 
gentleman from New Jersey, Chris Smith.
  Mr. SMITH of New Jersey. This week, another Planned Parenthood clinic 
director resigned after watching an ultrasound of an actual abortion in 
progress.
  Self-described as extremely pro-choice but now pro-life, Abby Johnson 
said she watched an unborn child ``crumple'' before her very eyes as 
the infant was vacuumed and dismembered by a suction device 20 to 30 
times more powerful than a household vacuum cleaner.
  Ms. Johnson said and told ABC News, ``I could see the baby try to 
move away. I just thought, `What am I doing?' ``Never again.''
  Mr. Speaker, abortion not only kills children; it harms women 
physically and psychologically, and it risks significant harm to 
subsequent children.
  Recently, the Times of London reported, ``Women who have had 
abortions have twice the level of psychological problems and three 
times the level of depression as women who have given birth or never 
been pregnant.'' The Times said ``senior obstetrians and psychiatrists 
say new evidence has uncovered a clear link between abortion and mental 
illness. . . .''
  Numerous studies show that the risk of preterm birth to children born 
to women who have had abortions increases. It skyrockets. One abortion 
preterm births goes up by 35 percent, two abortions a staggering 93 
percent. One of the the leading causes of mental and motor retardation 
is prematurity.
  We have and are going to have more disabling, because of abortion. If 
we truly don't want to see more abortions and if we want to reduce 
them, don't fund it.
  The Guttmacher Institute has said, formerly the research arm of 
Planned Parenthood, that prohibiting Federal funds for abortion reduces 
abortion by 25 percent.
  Millions of people are alive today because of the Hyde amendment, 
because funding was not there to effectuate their demise. Vote for the 
Stupak-Pitts amendment. It will save lives.
  The SPEAKER pro tempore. The gentleman from Michigan has 1 minute 
remaining.
  Mr. STUPAK. Mr. Speaker, to close on our side, I yield 1 minute to 
the gentlewoman from Ohio (Ms. Kaptur).
  Ms. KAPTUR. I thank the gentleman.
  With respect for all of my colleagues, I rise in support of the 
Stupak amendment, which maintains existing Federal law, the Hyde 
amendment, on the compelling issue of abortion.
  For 34 years, citizens of conscience have weighed in on this 
important moral and legal issue. Let me repeat: This amendment 
reaffirms longstanding, existing law and nothing more. It represents 
the broad consensus of the American people after 34 years of 
consideration on this issue. This is what it says:
  ``No Federal funds 'authorized under this act may be used to pay for 
any abortion or cover any part of the costs of any health plan that 
includes coverage of abortion,' except in the cases of the life of the 
mother, rape or incest.''
  The amendment does no more, no less. It is similar to language that 
applies in Federal law on Medicaid, Medicare, Veterans Affairs, the 
CHIP program, and the Federal Health Employees Program, which is a 
model for how this language should be applied. It has been tried, 
tested and proven. The inclusion of this amendment clarifies the bill's 
language on the potential fungibility of premium dollars.
  I urge my colleagues to support the amendment and the bill.
  Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to 
the gentlewoman from California (Mrs. Davis).
  Mrs. DAVIS of California. Mr. Speaker, I rise in opposition to this 
amendment.
  Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to 
the gentlewoman from Texas (Ms. Jackson-Lee).
  Ms. JACKSON-LEE of Texas. Mr. Speaker, I rise in strong opposition to 
this amendment.
  This amendment critically threatens women throughout America, and is 
unquestionably a

[[Page 27530]]

ban on abortion coverage. H.R. 3962 already provided for no federal 
dollars to be used for abortion--now this bill denies women the 
reimbursement for insurance to provide them good health care.
  This amendment acutely threatens the personal liberties of our 
country's most vulnerable women. It negatively affects these women's 
health, wellbeing, and financial security. This amendment will 
disproportionally affect women of color. According to the Center for 
Disease Control, ``the abortion ratio for black women (467 per 1,000 
live births) was 2.9 times the ratio for white women (158 per 1,000), 
and the ratio for women of the heterogeneous ``other'' race category 
(319 per 1,000) was 2.0 times the ratio for white women. The abortion 
rate for black women (28 per 1,000 women) was 3.1 times the rate for 
white women (nine per 1,000), whereas the abortion rate for women of 
other races (18 per 1,000 women) was 2.0 times the rate for white 
women.'' We should not be so naive to believe that these statistics 
represent anything less than the reality that minority women have less 
financial and personal autonomy. Women who decide to abort a pregnancy 
are not acting on whim or caprice. Rather, the decision to abort is a 
painful decision process borne out of necessity. I do not support these 
higher statistics among minority women, however their lives should not 
be jeopardized because of botched abortions.
  As a woman of faith myself, the issue of abortion is very dear to me. 
I must begin by saying that I am not pro-abortion, I am pro-choice. The 
early termination of a fetus is a terribly sad and unfortunate event, 
and the decision to abort is a long and difficult one. Situations arise 
in which a woman is forced to make the very tough decision about 
something very private and personal. In situations like this I believe 
strongly in a woman's right to choose. It is her body and any law 
prohibiting woman from having total control over their bodies is in 
violation of our constitutional rights.
  I have always supported a woman's right to choose. The decision to 
have a baby is something between a woman, her family, her faith and her 
doctor. This is an instance where the federal government does not need 
to be involved. It is my hope that society will continue to be 
progressive in their decisions, and if a woman decides to terminate her 
pregnancy, there are places that she can go to have the procedure done 
safely.
  The Supreme Court in 1973, in the landmark case of Roe v. Wade, ruled 
that a woman's right to have an abortion is a constitutionally 
protected right. Judge Blackmon wrote that ``a statute that 
criminalizes abortion is violative of the Due Process Clause of the 
Fourteenth Amendment and the abortion decision and its effectuation 
must be left to the medical judgment of the pregnant woman's attending 
physician.''
  The Stupak-Pitts amendment effectively reverses a women's control 
over her body. According to a 2002 study by the Guttmacher Institute, 
90 percent of private policies currently cover abortion services. If 
this amendment is adopted, it will instantly modify the insurance 
coverage for the millions of women whose current insurance plans 
include coverage for abortion care. These women entered into their 
insurance contracts with the guarantee that potential abortions would 
be covered. Yet, if this amendment is passed, every women covered under 
the new health care system would have to purchase supplemental 
insurance or pay out of pocket for abortions. It is estimated that one 
third of Americans will have an abortion in their lifetime. If this 
amendment is adopted, thousands of women will be unable to afford a 
procedure for unpredictable and unwanted pregnancies. This would 
essentially be a ban on abortions for these women.
  This is an unacceptable violation of a woman's personal sovereignty. 
I strongly oppose this amendment.
  Ms. DeGETTE. Mr. Speaker, the gentleman from Pennsylvania said 
exactly what the intention is here. The intention is not simply to 
expand the Hyde amendment. The base bill does that. The base bill says 
that no Federal funds will be used in this bill for abortion.
  It is the intention of our opponents to effectively stop a legal 
medical procedure from all plans that are in the exchange, even plans 
that are paid for with private dollars. This is the first time it would 
expand the Hyde exceptions to the private sector market. Mr. Speaker, 
it would not only affect the poor. It would affect the middle class.
  Vote ``no'' on this ill-conceived amendment.
  Ms. CHU. Mr. Speaker, I rise today in strong opposition to this 
amendment.
  Ms. HIRONO. Mr. Speaker, I rise today in strong opposition to the 
Stupak Amendment, an amendment that is anti-choice and anti-women.
  Earlier this week, I spoke about the importance of health care reform 
to women. If there was ever a group that has a lot at stake in reform, 
it is women. Health insurance companies today essentially treat being a 
woman as a pre-existing condition and charge them more for it. H.R. 
3962 will put an end to the unjustifiable insurance practices of 
gender-rating--treating pregnancy, domestic violence, and previous c-
section as pre-existing conditions--and not covering comprehensive 
maternity care. The men of this country would rise up in protest if 
they faced this kind of disparate treatment based on conditions 
particular to their gender.
  The Stupak Amendment would effectively deny low-income women abortion 
coverage through insurance plans in the health insurance exchange. This 
is not only discriminatory but dangerous to women's health. Women 
without abortion coverage will be forced to postpone abortion care 
while attempting to raise the necessary funds--a delay that can 
exacerbate both the costs and the health risks of the procedure.
  As a woman, I find it frankly insulting that the amendment would make 
women purchase additional insurance coverage for a legal medical 
procedure. We aren't asking individuals to purchase additional coverage 
in case they get cancer or in case they get diabetes. We aren't 
flagging out any other legal medical procedures to be treated in this 
manner.
  Women do not plan to have unintended pregnancies or pregnancies with 
complications that create health risks. And yet unintended pregnancies 
and complications do arise. This amendment says it's okay to tell 
women, if you want to guard against these situations, go buy a rider. 
This is a deeply insulting attitude. An abortion rider policy also 
raises serious privacy concerns, as it fundamentally undermines the 
spirit of existing privacy law.
  The sponsors of the amendment have consistently failed to highlight 
that the bill already contains a compromise that stipulates that state 
laws regarding abortion procedures are not pre-empted. The bill already 
states that no federal funds--neither tax nor cost sharing tax 
credits--can be used to pay for abortion procedures.
  Before taking this vote, I urge my colleagues who support this 
amendment to think about the women in their lives, their mothers, 
sisters, daughters, granddaughters. Would they put the lives of these 
women at risk? Would they take away their fundamental rights of choice 
and freedom? Would they want to limit their access to any legal medical 
procedure? I ask these questions of my colleagues because in voting in 
support of the Stupak Amendment, they are answering yes to all these 
questions.
  I urge my colleagues to join me in voting ``no'' on the amendment.
  Ms. HARMAN. Mr. Speaker, It is going to be very difficult for me to 
vote for a health care bill that contains the Stupak amendment on 
abortion.
  Far from codifying the Hyde language, which has been included in 
House appropriations bills since 1976, the Stupak amendment would 
essentially make it impossible for most women to use their own funds to 
purchase insurance to pay for abortions. This is not chipping away at a 
woman's right to choose, this is an outright assault on my 
constitutional rights--and it is wrong.
  I respect the right of any woman or man to oppose abortion. But, in 
return, I expect those who are anti-choice to respect my views. My 
views are that abortion should be safe and rare--but that a woman's 
constitutional right to privacy as articulated in Roe v. Wade is 
inviolable.
  I am old enough to remember the days of back alley abortions. Some 
women I know had them. I cannot bear the idea that the 111th Congress 
would restore that horror.
  The Stupak amendment is insulting and destructive. Its passage would 
pair us with the government of Afghanistan in sending women's rights 
back to the Stone Age. I intend to vote for this bill, but if it 
contains the Stupak amendment when it emerges from Conference 
Committee, my conscience demands that I reconsider my support.
  Ms. McCOLLUM. Mr. Speaker, every member of this House has the right 
to their own opinions and views on issues related to health care 
reform--including women's reproductive health care issues. However, as 
comprehensive healthcare legislation reaches the House floor for a 
vote, Congress must not violate the first tenant of the entire reform 
effort, which is to ensure that no one loses healthcare coverage they 
currently have.
  Today we have an amendment on the floor that bans legal reproductive 
health care services for woman who pay for their own health

[[Page 27531]]

insurance. This amendment is wrong, it is dangerous, and it should be 
defeated.
  The opportunity to meet the health care needs of all Americans is the 
strength of the bill we are debating. I want every American to have 
access to affordable, quality health care. This amendment and the work 
of many special interest groups to use this amendment to undermine 
health care reform is a transparent political game that puts millions 
of Americans at risk. Single issue political games must not be used to 
deny health care to millions of Americans.
  I would like to submit for the Record a statement by a broad 
coalition of Minnesota religious leaders who call health care reform a 
matter of social justice that should not be undone by a single issue. 
These religious leaders understand the complex personal decision making 
that goes into health care choices, but they also know that Americans 
without access to health care too often have no choice except to suffer 
and too often endure conditions that result in severe illness or even 
preventable death.
  These religious leaders are an inspiration to me. They are helping to 
frame the social, economic, moral and spiritual importance of passing 
health care reform legislation in Congress.

                                                 November 7, 2009.
       As more Americans lose jobs and insurance coverage, health 
     care reform bills are moving to final votes in Congress. 
     Instead of working toward the reform that is so desperately 
     needed, some groups, including the United States Conference 
     of Catholic Bishops, are working overtime to ensure that 
     women are denied the comprehensive health care they currently 
     have.
       With all the hyperbole, we have lost sight of the original 
     goal of health reform: to expand access to health care, 
     improve quality, and reduce costs--not to litigate abortion 
     rights. As Congress works toward health care reform, they 
     must make women's health a priority and guarantee that 
     reproductive health care is covered.
       Our faith traditions are abundantly clear about living in 
     community with others and being responsible for them. Our 
     traditions share the common core of serving those most in 
     need. We join with others in expressing the need for us to 
     return to the core of our faith traditions and realize that 
     providing access to safe and quality health care makes sense 
     morally, ethically, spiritually, and financially.
       The president has repeatedly stated that no one should lose 
     the coverage she or he currently has under health care 
     reform. But, if dangerous amendments put forth by the vocal 
     minority in Washington aren't defeated, women will lose their 
     benefits, plain and simple.
       It's simply untrue that abortion coverage will be mandated 
     under the proposed new health plan. Simply put, Federal money 
     would not pay for abortion care.
       In fact, the House bill contains carefully crafted 
     compromise language that allows women to keep the benefits 
     they currently have while also ensuring that no federal 
     funding is used for abortions.
       Rep. Lois Capps drafted this provision to address both pro-
     life and pro-choice concerns around health care reform and 
     balance both sides of the issue. The Capps proposal maintains 
     the current policy of restricting federal funding for 
     abortions and ensures that women won't lose benefits they 
     currently have and will have access to insurance that covers 
     abortion if they want it. Further, it expressly prohibits the 
     use of federal funds to pay for abortion care.
       This is an even-handed compromise supported by people on 
     both sides of the issue. While reasonable people disagree 
     over the issue of abortion, no woman wants her health to be 
     the object of political gamesmanship in this debate. That's 
     why the Capps proposal was created. It's a common sense 
     solution to help health care reform move forward with the 
     support of the mainstream on all sides of the issue.
       As religious leaders, we support public policies that are 
     just and compassionate and prioritize the needs of those who 
     are poor and marginalized in our society. In this religiously 
     pluralistic nation, our health care system should be 
     inclusive and respectful of diverse religious beliefs and 
     decisions regarding childbearing. A health care system that 
     serves all persons with dignity and equality will include 
     comprehensive reproductive health services.
       Health care reform is far too important a social justice 
     issue to be left to chance and overheated rhetoric. It's time 
     to move forward for the good of American women and families.

       Members and Friends of the Minnesota Religious Coalition 
     for Reproductive Choice; Rev. Judith Allen Kim, Presbytery of 
     the Twin Cities Area; The Rev. Norma Burton, Linden Hills 
     United Church of Christ, Minneapolis; Kelli Clement, 
     Candidate for Ministry, UUA; Rev. Doug Donley, University 
     Baptist Church, Minneapolis; Rev. Dr. Rob Eller-Isaacs, and 
     Rev. Dr. Janne Eller-Isaacs, Co-Ministers, Unity Church 
     Unitarian, St. Paul; Rev. Dr. Kendyl Gibbons, Sr. Minister, 
     First Unitarian Society of Minneapolis; Rev. Walter Lockhart 
     IV, Walker Community United Methodist Church, Minneapolis; 
     Rev. Meg Riley, Unitarian Universalist Association; Rev. T. 
     Michael Rock, Robbinsdale United Church of Christ; Kiely Todd 
     Roska, United Church of Christ in New Brighton; Rev. Dr. 
     Christine M. Smith, Cherokee Park United Church, St. Paul; 
     Rev. Victoria Safford, White Bear Unitarian Universalist 
     Church, Mahtomedi; Rabbi Jared Saks, Temple Israel, 
     Minneapolis; Barbara Schmiechen, Linden Hills United Church 
     of Christ, Minneapolis; and Rev. Daniel R. Schmiechen, Linden 
     Hills United Church of Christ, Minneapolis.

  Mr. MORAN of Kansas. Mr. Speaker, I rise in support of the Stupak-
Pitts Amendment to H.R. 3962, Speaker Pelosi's health care reform bill. 
This amendment would maintain the current policy of preventing federal 
funding for abortion and for health benefits packages that include 
abortion. I feel a special obligation to protect innocent, young life.
  I recently sponsored H. Con. Res. 169, legislation urging members of 
Congress to eliminate taxpayer-funded abortions from any proposed 
health care reform package. Directing taxpayer dollars to fund 
abortions is a clear violation of many Americans' deeply held beliefs 
and Americans should not be forced to compromise their core moral 
beliefs as a means to health care reform. Additionally, on September 
28, 2009, I urged Speaker Pelosi and Democratic leadership, along with 
182 of my House colleagues, to allow members of the House to vote their 
consciences with regard to abortion and health care reform by allowing 
consideration of an amendment to prohibit government funding of 
abortion.
  Ms. BORDALLO. Mr. Speaker, I rise today in support of the Stupak-
Ellsworth-Pitts-Smith-Kaptur-Dahlkemper Amendment to H.R. 3962 the 
``Affordable Health Care for America Act.'' This amendment, supported 
by the United States Conference of Catholic Bishops, is important 
because it ensures that current federal law on abortion funding will 
apply to the public health care option created by H.R. 3962.
  This amendment codifies the Hyde Amendment in H.R. 3962. It will 
prevent public funds from being used to pay for or subsidize elective 
abortions, either through the public option or heath care affordability 
tax credits, except in the case of rape, incest, physical injury or 
physical illness to the women. The Hyde Amendment is already in place 
in current federal health programs like Medicaid and Medicare and this 
amendment will make sure that H.R. 3962 is governed in a consistent 
manner.
  I have received numerous letters from my constituents expressing both 
support for health care reform, but also grave concerns that federal 
funds would be used to pay for elective abortion under the new law. I 
am very supportive of the overall goals of H.R. 3962 and particularly 
its provisions that address the health disparity issues in the 
territories. The addition of the Stupak-Ellsworth-Pitts-Smith-Kaptur-
Dahlkemper amendment will further strengthen this legislation and 
ensure that no one will need to choose between their conscientious 
objections to abortion and their desire to work toward more affordable 
quality health care in America.
  I commend Congressman Stupak for his leadership on this important 
issue and urge my colleagues to support this amendment.
  Mr. FARR. Mr. Speaker, I rise to express my strong opposition to the 
Stupak-Pitts amendment.
  The health care bill before the House tonight retains existing law on 
the ban on federal dollars being used for abortion services in federal 
programs. This health care bill does what it promised to do: not to 
expand abortion services. But the Stupak amendment wants to rewrite 
current law. This amendment ignores the constitutionally protected 
right for women to choose their reproductive health care. It makes 
women, and only women, have to purchase an additional policy with their 
own money to cover women's reproductive health care.
  That we are considering outlawing a medical procedure--one chosen by 
patients and their doctors--in existing law. This amendment makes it 
impossible for women to purchase health care insurance to cover a 
health care procedure that can only be needed at a time of crisis. It 
would require women to plan for an unplanned pregnancy. That is plain 
wrong.
  When will we stop treating women like second class citizens? When 
will we admit that they have the right to determine their health care 
like anyone else? Why are we boxing them in with this amendment that 
restricts and restrains their ability to act in a manner they deem 
appropriate for their well-being? Shame on us for being so 
disrespectful of their humanity and for attempting to disenfranchise 
them this way.
  If we want health care for all Americans then women should be 
entitled to all health care, not just some aspects of it.
  Ms. ESHOO. Mr. Speaker, I come to the floor today to oppose the 
amendment offered

[[Page 27532]]

by my colleague, Representative Bart Stupak. I know that he is 
following his own conscience, but I want to preserve the right of women 
nationwide to follow their conscience as well. I support a woman's 
right to be either for or against abortion. The decision is a private 
one and it is a matter of faith as well as a matter of conscience, and 
it is supported by our Constitution.
  This amendment is not about federal funding for abortion . . . the 
current version of the bill and federal law, the Hyde Amendment, 
already prohibit spending tax dollars to finance abortions. This 
amendment goes beyond that language. It prohibits private health 
insurance plans that receive even one dollar of federal funding to 
offer abortion services to any of their customers. This eliminates 
coverage for an important health service that millions of women 
currently have. This amendment leaves women even worse off than they 
are now. I cannot support such all-encompassing language.
  There is a certain irony here that demonstrates how prejudiced this 
amendment is toward women. Insurance plans would allow a man to obtain 
Viagra and cause an unwanted pregnancy, but it penalizes women for 
becoming pregnant.
  Insurance is intended to cover the unexpected. Yet, this amendment 
would deny women the right to purchase their own coverage as part of a 
regular insurance plan. It will heap an ugly punishment upon those who 
often times can least afford it, and it will push women into the past 
of back-alley butchers.
  Today women are entitled under the law to a safe abortion. It is 
estimated that in California before the Roe v. Wade decision, about 
100,000 illegal abortions were performed each year. Abortion was the 
most common single cause of maternal deaths in California prior to 
1973. We should not turn back the clock. As we work to provide 
universal health for all our citizens, women should be protected. This 
amendment does nothing to advance this and I ask my colleagues to 
defeat it.
  Ms. SPEIER. Mr. Speaker, tonight as we prepare to pass a historic 
health care bill that provides expanded health care coverage to 
Americans and is more than sixty years in the making, I am concerned 
that we must first fight to block a direct assault on a woman's right 
to choose.
  America's Affordable Health Choices Act is fair and equitable in its 
approach to abortion and respects the rights of those who want to 
purchase a plan that provides abortion coverage and those who do not. 
It guarantees that no public funds are used to pay for abortion 
services--codifying the long standing Hyde amendment.
  The anti-choice Stupak Amendment seeks to take away a woman's right 
to pay for her own abortion services, forcing millions of women to 
retreat to the shadows and an era in which back alley abortions were 
too often the norm. That is why I will stand up this evening and vote 
against the Stupak Amendment--ensuring that every woman in this country 
has the reproductive freedom that she desires and that her mother and 
mother's mother fought so hard for.
  Mr. POLIS. Mr. Speaker, I would like to express my strong opposition 
to the Stupak/Pitts Amendment, which unfortunately passed the House by 
a vote of 240-194. This amendment places a woman's right to choose at 
risk, for it would place new obstacles in the way of women seeking 
reproductive health care services. The Stupak Amendment goes further 
than existing laws. This amendment dictates which medical procedures 
are offered in the private market.
  Health care reform is supposed to increase coverage. This amendment 
singles out women and reduces their coverage. Women's access to 
comprehensive reproductive health services is not just about equality 
between men and women but also equality along economic lines. This 
amendment sets up a system where only wealthier women could afford a 
safe abortion. It would prohibit low-income women who receive 
affordability tax credits from purchasing a private insurance plan that 
covers abortion, despite the fact that over 80 percent of health 
insurance plans currently cover abortion. In other words, a woman who 
happens to be low-income will be denied the right to purchase a health 
care plan with abortion coverage simply because she qualifies for 
affordability tax credits. This is discriminatory, plain and simple.
  Besides purchasing insurance in the exchange, the primary alternative 
for low-income individuals is the public option. Not only does this 
amendment prohibit access to abortion coverage if a low-income woman 
receives affordability tax credits in the exchange, but this amendment 
also prohibits the public option from providing abortion care, despite 
the fact that it would be funded through private premium dollars.
  Under the Stupak Amendment, low-income women who either receive 
affordability tax credits or purchase insurance through the public 
option have to purchase a separate, single-service ``abortion rider'' 
policy. Not only does this idea discriminate against low-income women 
but it makes no sense either. Women who end up in the tough position of 
having to seek an abortion never planned on being in that situation. 
The vast majority of women will not choose to purchase an ``abortion 
rider'' policy because they do not plan on ever having an abortion, and 
when the day arises when they may need abortion coverage, unfortunately 
it will not be there for them.
  The women of America should have access to their fundamental right to 
choose, regardless of their income level. I urge my colleagues to join 
me today in defense of that fundamental right.
  Ms. EDWARDS of Maryland. Mr. Speaker, I object to the anti-choice 
amendment brought forward by Reps. Bart Stupak and Joseph Pitts. The 
Stupak-Pitts amendment goes beyond the scope of current law and 
effectively prohibits private insurers in the health insurance Exchange 
from offering insurance plans with abortion provisions. This amendment 
prohibits the use of federal funds from covering any part of the costs 
of any health care plan that includes coverage of abortion coverage, 
even if federal dollars do not go towards an abortion procedure. This 
amendment truly undermines the spirit of health care reform by 
rationing women's care and taking away current benefits plans that 
include abortion coverage.
  This amendment strips women's legal right to abortion procedures and 
turns back the clock on decades of legal precedent and legislation.
  This is a procedure that some women must consider in the interest of 
their health. This is a choice that no one, not a Member of Congress, 
or government official should make for a woman. This is a woman's 
choice that must be preserved. A woman's reproductive choice has been 
recognized by the Supreme Court of this country, and honored by the 
citizens and lawmakers of this country.
  Please oppose this amendment and protect women's health.
  Ms. KAPTUR. Mr. Speaker, I rise in support of the Stupak-Ellsworth-
Pitts-Smith-Kaptur-Dahlkemper Amendment that maintains existing Federal 
law on the compelling issue of abortion. For 34 years, citizens of 
conscience on all sides have weighed in on this important moral and 
legal question. Lawmakers have attempted to accommodate very divergent 
views, even on the meaning of life itself. Many lives must be 
considered--the life of the mother, the life of the child, including 
the unborn but conceived, and in my opinion the rarely mentioned 
responsibilities of the father as well.
  Our legislative struggle to do what is proper is rooted in 
interrelated moral, scientific, legal, and yes, theological 
dissonances. What is right? What should be legal? And what will lead to 
a just and responsible society for all? I continue to approach this 
deeply moving issue as a representative from a widely diverse 
Congressional district in northwestern Ohio, an area of our Nation 
comprised of people from many different ethnicities, races, faiths, 
denominations and belief systems. My representation of these varying 
views embodies the deepest respect for all our people, and for the 
integrity with which they have arrived at their values.
  This amendment reaffirms longstanding, existing law, and nothing 
more. It represents the broad consensus of the American people after 
decades of consideration on the issue. Recent Gallup polls show that 51 
percent of Americans consider themselves ``pro-life'' on the issue of 
abortion. But, this amendment does not resolve all moral questions that 
face pro choice, prolife, and non-aligned Americans on this issue. All 
it does is restate existing law.
  It states that no Federal funds ``authorized under this Act may be 
used to pay for any abortion, or to cover any part of the costs of any 
health plan that includes coverage of abortion,'' except in the cases 
of the life of the mother, rape or incest.
  Effectively, the precedent setting Hyde amendment--which has been in 
effect for 34 years in our Nation--will apply to the public option, and 
to any Federal plans which include elective abortion. The amendment 
does no more, and no less. Further, with the added coverage for all 
Americans that this bill provides, perhaps the abortion choice will 
become less attractive for those faced with such a life wrenching 
choice.
  This amendment will not bar any one from purchasing their own private 
supplemental rider. Our language is the same that applies in current 
law on Medicaid, Medicare, the Children's Health Insurance Plan, and 
the Federal Employee Health Benefits Plan, FEHBP, itself which offers 
many private insurance plans.

[[Page 27533]]

The FEHBP is a model for how this language will be applied. It has been 
tried, tested, and proven.
  The inclusion of this amendment clarifies the bill's language on the 
potential fungibility of premium dollars deposited in Federal accounts 
that could result in federally sanctioned insurance paid for by taxes, 
premiums, or Federal subsidies diverted to pay for abortions by those 
who do not agree with the procedure.
  Importantly, for the first time, the base measure itself will help 
vast scores of women to obtain health coverage and, by so doing limit 
abortion by enhancing broad coverage options for women's and children's 
health. The rate of infant mortality, which is fueled by shamefully 
high rates of premature birth in the United States, shows us that we 
are not addressing the needs of mother's and their babies. Providing 
the necessary support for women is the answer. This bill will vastly 
improve preventive care, double funds available to community health 
centers including obstetric and gynecological care, and move America 
fully into this 21st century. No woman, no woman--including poor women, 
pregnant women, unemployed women, working women, single women, and 
nursing women--will be left out of health insurance coverage.
  I urge my colleagues to support the amendment.
  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
previous question is ordered on the amendment.
  The question is on the amendment offered by the gentleman from 
Michigan (Mr. Stupak).
  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.
  Mr. STUPAK. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to section 2 of House Resolution 
903, further proceedings on this question will be postponed.


                    Amendment Offered by Mr. Boehner

  Mr. BOEHNER. Mr. Speaker, pursuant to the rule, I call up the 
amendment in the nature of a substitute printed in the rule.
  The SPEAKER pro tempore (Mr. Obey). The Clerk will designate the 
amendment.
  The text of the amendment is as follows:

       Part D amendment in the nature of a substitute printed in 
     House Report 111-330 offered by Mr. Boehner:
       Strike all after the enacting clause and insert the 
     following:

     SECTION 1. SHORT TITLE; PURPOSE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Common 
     Sense Health Care Reform and Affordability Act''.
       (b) Purpose.--The purpose of this Act is to take meaningful 
     steps to lower health care costs and increase access to 
     health insurance coverage (especially for individuals with 
     preexisting conditions) without--
       (1) raising taxes;
       (2) cutting Medicare benefits for seniors;
       (3) adding to the national deficit;
       (4) intervening in the doctor-patient relationship; or
       (5) instituting a government takeover of health care.
       (c) Table of Contents.--The table of contents of this Act 
     is as follows:

Sec. 1. Short title; purpose; table of contents.

 DIVISION A--MAKING HEALTH CARE COVERAGE AFFORDABLE FOR EVERY AMERICAN

TITLE I--ENSURING COVERAGE FOR INDIVIDUALS WITH PREEXISTING CONDITIONS 
                     AND MULTIPLE HEALTH CARE NEEDS

Sec. 101. Establish universal access programs to improve high risk 
              pools and reinsurance markets.
Sec. 102. Elimination of certain requirements for guaranteed 
              availability in individual market.
Sec. 103. No annual or lifetime spending caps.
Sec. 104. Preventing unjust cancellation of insurance coverage.

  TITLE II--REDUCING HEALTH CARE PREMIUMS AND THE NUMBER OF UNINSURED 
                               AMERICANS

Sec. 111. State innovation programs.
Sec. 112. Health plan finders.
Sec. 113. Administrative simplification.

              DIVISION B--IMPROVING ACCESS TO HEALTH CARE

   TITLE I--EXPANDING ACCESS AND LOWERING COSTS FOR SMALL BUSINESSES

Sec. 201. Rules governing association health plans.
Sec. 202. Clarification of treatment of single employer arrangements.
Sec. 203. Enforcement provisions relating to association health plans.
Sec. 204. Cooperation between Federal and State authorities.
Sec. 205. Effective date and transitional and other rules.

              TITLE II--TARGETED EFFORTS TO EXPAND ACCESS

Sec. 211. Extending coverage of dependents.
Sec. 212. Allowing auto-enrollment for employer sponsored coverage.

 TITLE III--EXPANDING CHOICES BY ALLOWING AMERICANS TO BUY HEALTH CARE 
                      COVERAGE ACROSS STATE LINES

Sec. 221. Interstate purchasing of Health Insurance.

              TITLE IV--IMPROVING HEALTH SAVINGS ACCOUNTS

Sec. 231. Saver's credit for contributions to health savings accounts.
Sec. 232. HSA funds for premiums for high deductible health plans.
Sec. 233. Requiring greater coordination between HDHP administrators 
              and HSA account administrators so that enrollees can 
              enroll in both at the same time.
Sec. 234. Special rule for certain medical expenses incurred before 
              establishment of account.

           DIVISION C--ENACTING REAL MEDICAL LIABILITY REFORM

Sec. 301. Encouraging speedy resolution of claims.
Sec. 302. Compensating patient injury.
Sec. 303. Maximizing patient recovery.
Sec. 304. Additional health benefits.
Sec. 305. Punitive damages.
Sec. 306. Authorization of payment of future damages to claimants in 
              health care lawsuits.
Sec. 307. Definitions.
Sec. 308. Effect on other laws.
Sec. 309. State flexibility and protection of states' rights.
Sec. 310. Applicability; effective date.

         DIVISION D--PROTECTING THE DOCTOR-PATIENT RELATIONSHIP

Sec. 401. Rule of construction.
Sec. 402. Repeal of Federal Coordinating Council for Comparative 
              Effectiveness Research.

      DIVISION E--INCENTIVIZING WELLNESS AND QUALITY IMPROVEMENTS

Sec. 501. Incentives for prevention and wellness programs.

                    DIVISION F--PROTECTING TAXPAYERS

Sec. 601. Provide full funding to HHS OIG and HCFAC.
Sec. 602. Prohibiting taxpayer funded abortions and conscience 
              protections.
Sec. 603. Improved enforcement of the Medicare and Medicaid secondary 
              payer provisions.
Sec. 604. Strengthen Medicare provider enrollment standards and 
              safeguards.
Sec. 605. Tracking banned providers across State lines.

         DIVISION G--PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS

Sec. 701. Licensure pathway for biosimilar biological products.
Sec. 702. Fees relating to biosimilar biological products.
Sec. 703. Amendments to certain patent provisions.

 DIVISION A--MAKING HEALTH CARE COVERAGE AFFORDABLE FOR EVERY AMERICAN

TITLE I--ENSURING COVERAGE FOR INDIVIDUALS WITH PREEXISTING CONDITIONS 
                     AND MULTIPLE HEALTH CARE NEEDS

     SEC. 101. ESTABLISH UNIVERSAL ACCESS PROGRAMS TO IMPROVE HIGH 
                   RISK POOLS AND REINSURANCE MARKETS.

       (a) State Requirement.--
       (1) In general.--Not later than January 1, 2010, each State 
     shall--
       (A) subject to paragraph (3), operate--
       (i) a qualified State reinsurance program described in 
     subsection (b); or
       (ii) qualifying State high risk pool described in 
     subsection (c)(1); and
       (B) subject to paragraph (3), apply to the operation of 
     such a program from State funds an amount equivalent to the 
     portion of State funds derived from State premium assessments 
     (as defined by the Secretary) that are not otherwise used on 
     State health care programs.
       (2) Relation to current qualified high risk pool program.--
       (A) States not operating a qualified high risk pool.--In 
     the case of a State that is not operating a current section 
     2745 qualified high risk pool as of the date of the enactment 
     of this Act--
       (i) the State may only meet the requirement of paragraph 
     (1) through the operation of a qualified State reinsurance 
     program described in subsection (b); and
       (ii) the State's operation of such a reinsurance program 
     shall be treated, for purposes of section 2745 of the Public 
     Health Service Act, as the operation of a qualified high risk 
     pool described in such section.
       (B) State operating a qualified high risk pool.--In the 
     case of a State that is operating a current section 2745 
     qualified high risk pool as of the date of the enactment of 
     this Act--

[[Page 27534]]

       (i) as of January 1, 2010, such a pool shall not be treated 
     as a qualified high risk pool under section 2745 of the 
     Public Health Service Act unless the pool is a qualifying 
     State high risk pool described in subsection (c)(1); and
       (ii) the State may use premium assessment funds described 
     in paragraph (1)(B) to transition from operation of such a 
     pool to operation of a qualified State reinsurance program 
     described in subsection (b).
       (3) Application of funds.--If the program or pool operated 
     under paragraph (1)(A) is in strong fiscal health, as 
     determined in accordance with standards established by the 
     National Association of Insurance Commissioners and as 
     approved by the State Insurance Commissioner involved, the 
     requirement of paragraph (1)(B) shall be deemed to be met.
       (b) Qualified State Reinsurance Program.--
       (1) In general.--For purposes of this section, a 
     ``qualified State reinsurance program'' means a program 
     operated by a State program that provides reinsurance for 
     health insurance coverage offered in the small group market 
     in accordance with the model for such a program established 
     (as of the date of the enactment of this Act).
       (2) Form of program.--A qualified State reinsurance program 
     may provide reinsurance--
       (A) on a prospective or retrospective basis; and
       (B) on a basis that protects health insurance issuers 
     against the annual aggregate spending of their enrollees as 
     well as purchase protection against individual catastrophic 
     costs.
       (3) Satisfaction of hipaa requirement.--A qualified State 
     reinsurance program shall be deemed, for purposes of section 
     2745 of the Public Health Service Act, to be a qualified 
     high-risk pool under such section.
       (c) Qualifying State High Risk Pool.--
       (1) In general.--A qualifying State high risk pool 
     described in this subsection means a current section 2745 
     qualified high risk pool that meets the following 
     requirements:
       (A) The pool must provide at least two coverage options, 
     one of which must be a high deductible health plan coupled 
     with a health savings account.
       (B) The pool must be funded with a stable funding source.
       (C) The pool must eliminate any waiting lists so that all 
     eligible residents who are seeking coverage through the pool 
     should be allowed to receive coverage through the pool.
       (D) The pool must allow for coverage of individuals who, 
     but for the 24-month disability waiting period under section 
     226(b) of the Social Security Act, would be eligible for 
     Medicare during the period of such waiting period.
       (E) The pool must limit the pool premiums to no more than 
     150 percent of the average premium for applicable standard 
     risk rates in that State.
       (F) The pool must conduct education and outreach 
     initiatives so that residents and brokers understand that the 
     pool is available to eligible residents.
       (G) The pool must provide coverage for preventive services 
     and disease management for chronic diseases.
       (2) Verification of citizenship or alien qualification.--
       (A) In general.--Notwithstanding any other provision of 
     law, only citizens and nationals of the United States shall 
     be eligible to participate in a qualifying State high risk 
     pool that receives funds under section 2745 of the Public 
     Health Service Act or this section.
       (B) Condition of participation.--As a condition of a State 
     receiving such funds, the Secretary shall require the State 
     to certify, to the satisfaction of the Secretary, that such 
     State requires all applicants for coverage in the qualifying 
     State high risk pool to provide satisfactory documentation of 
     citizenship or nationality in a manner consistent with 
     section 1903(x) of the Social Security Act.
       (C) Records.--The Secretary shall keep sufficient records 
     such that a determination of citizenship or nationality only 
     has to be made once for any individual under this paragraph.
       (3) Relation to section 2745.--As of January 1, 2010, a 
     pool shall not qualify as qualified high risk pool under 
     section 2745 of the Public Health Service Act unless the pool 
     is a qualifying State high risk pool described in paragraph 
     (1).
       (d) Waivers.--In order to accommodate new and innovative 
     programs, the Secretary may waive such requirements of this 
     section for qualified State reinsurance programs and for 
     qualifying State high risk pools as the Secretary deems 
     appropriate.
       (e) Funding.--In addition to any other amounts 
     appropriated, there is appropriated to carry out section 2745 
     of the Public Health Service Act (including through a program 
     or pool described in subsection (a)(1))--
       (1) $15,000,000,000 for the period of fiscal years 2010 
     through 2019; and
       (2) an additional $10,000,000,000 for the period of fiscal 
     years 2015 through 2019.
       (f) Definitions.--In this section:
       (1) Health insurance coverage; health insurance issuer.--
     The terms ``health insurance coverage'' and ``health 
     insurance issuer'' have the meanings given such terms in 
     section 2791 of the Public Health Service Act.
       (2) Current section 2745 qualified high risk pool.--The 
     term ``current section 2745 qualified high risk pool'' has 
     the meaning given the term ``qualified high risk pool'' under 
     section 2745(g) of the Public Health Service Act as in effect 
     as of the date of the enactment of this Act.
       (3) Secretary.--The term ``Secretary'' means Secretary of 
     Health and Human Services.
       (4) Standard risk rate.--The term ``standard risk rate'' 
     means a rate that--
       (A) is determined under the State high risk pool by 
     considering the premium rates charged by other health 
     insurance issuers offering health insurance coverage to 
     individuals in the insurance market served;
       (B) is established using reasonable actuarial techniques; 
     and
       (C) reflects anticipated claims experience and expenses for 
     the coverage involved.
       (5) State.--The term ``State'' means any of the 50 States 
     or the District of Columbia.

     SEC. 102. ELIMINATION OF CERTAIN REQUIREMENTS FOR GUARANTEED 
                   AVAILABILITY IN INDIVIDUAL MARKET.

       (a) In General.--Section 2741(b) of the Public Health 
     Service Act (42 U.S.C. 300gg-41(b)) is amended----
       (1) in paragraph (1)--
       (A) by striking ``(1)(A)'' and inserting ``(1)''; and
       (B) by striking ``and (B)'' and all that follows up to the 
     semicolon at the end;
       (2) by adding ``and'' at the end of paragraph (2);
       (3) in paragraph (3)--
       (A) by striking ``(1)(A)'' and inserting ``(1)''; and
       (B) by striking the semicolon at the end and inserting a 
     period; and
       (4) by striking paragraphs (4) and (5).
       (b) Effective Date.--The amendments made by subsection (a) 
     shall take effect on the date of the enactment of this Act.

     SEC. 103. NO ANNUAL OR LIFETIME SPENDING CAPS.

       Notwithstanding any other provision of law, a health 
     insurance issuer (including an entity licensed to sell 
     insurance with respect to a State or group health plan) may 
     not apply an annual or lifetime aggregate spending cap on any 
     health insurance coverage or plan offered by such issuer.

     SEC. 104. PREVENTING UNJUST CANCELLATION OF INSURANCE 
                   COVERAGE.

       (a) Clarification Regarding Application of Guaranteed 
     Renewability of Individual Health Insurance Coverage.--
     Section 2742 of the Public Health Service Act (42 U.S.C. 
     300gg-42) is amended--
       (1) in its heading, by inserting ``, continuation in force, 
     including prohibition of rescission,'' after ``guaranteed 
     renewability'';
       (2) in subsection (a), by inserting ``, including without 
     rescission,'' after ``continue in force''; and
       (3) in subsection (b)(2), by inserting before the period at 
     the end the following: ``, including intentional concealment 
     of material facts regarding a health condition related to the 
     condition for which coverage is being claimed''.
       (b) Opportunity for Independent, External Third Party 
     Review in Certain Cases.--Subpart 1 of part B of title XXVII 
     of the Public Health Service Act is amended by adding at the 
     end the following new section:

     ``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD 
                   PARTY REVIEW IN CERTAIN CASES.

       ``(a) Notice and Review Right.--If a health insurance 
     issuer determines to nonrenew or not continue in force, 
     including rescind, health insurance coverage for an 
     individual in the individual market on the basis described in 
     section 2742(b)(2) before such nonrenewal, discontinuation, 
     or rescission, may take effect the issuer shall provide the 
     individual with notice of such proposed nonrenewal, 
     discontinuation, or rescission and an opportunity for a 
     review of such determination by an independent, external 
     third party under procedures specified by the Secretary.
       ``(b) Independent Determination.--If the individual 
     requests such review by an independent, external third party 
     of a nonrenewal, discontinuation, or rescission of health 
     insurance coverage, the coverage shall remain in effect until 
     such third party determines that the coverage may be 
     nonrenewed, discontinued, or rescinded under section 
     2742(b)(2).''.
       (c) Effective Date.--The amendments made by this section 
     shall apply after the date of the enactment of this Act with 
     respect to health insurance coverage issued before, on, or 
     after such date.

  TITLE II--REDUCING HEALTH CARE PREMIUMS AND THE NUMBER OF UNINSURED 
                               AMERICANS

     SEC. 111. STATE INNOVATION PROGRAMS.

       (a) Programs That Reduce the Cost of Health Insurance 
     Premiums.--
       (1) Payments to states.--
       (A) For premium reductions in the small group market.--If 
     the Secretary determines that a State has reduced the average 
     per capita premium for health insurance coverage in the small 
     group market in year 3, in year 6, or year 9 (as defined in 
     subsection (c)) below the premium baseline for such year (as

[[Page 27535]]

     defined paragraph (2)), the Secretary shall pay the State an 
     amount equal to the product of--
       (i) bonus premium percentage (as defined in paragraph (3)) 
     for the State, market, and year; and
       (ii) the maximum State premium payment amount (as defined 
     in paragraph (4)) for the State, market, and year
       (B) For premium reductions in the individual market.--If 
     the Secretary determines that a State has reduced the average 
     per capita premium for health insurance coverage in the 
     individual market in year 3, in year 6, or in year 9 below 
     the premium baseline for such year, the Secretary shall pay 
     the State an amount equal to the product of--
       (i) bonus premium percentage for the State, market, and 
     year; and
       (ii) the maximum State premium payment amount for the 
     State, market, and year.
       (2) Premium baseline.--For purposes of this subsection, the 
     term ``premium baseline'' means, for a market in a State--
       (A) for year 1, the average per capita premiums for health 
     insurance coverage in such market in the State in such year; 
     or
       (B) for a subsequent year, the baseline for the market in 
     the State for the previous year under this paragraph 
     increased by a percentage specified in accordance with a 
     formula established by the Secretary, in consultation with 
     the Congressional Budget Office and the Bureau of the Census, 
     that takes into account at least the following:
       (i) Growth factor.--The inflation in the costs of inputs to 
     health care services in the year.
       (ii) Historic premium growth rates.--Historic growth rates, 
     during the 10 years before year 1, of per capita premiums for 
     health insurance coverage.
       (iii) Demographic considerations.--Historic average changes 
     in the demographics of the population covered that impact on 
     the rate of growth of per capita health care costs.
       (3) Bonus premium percentage defined.--
       (A) In general.--For purposes of this subsection, the term 
     ``bonus premium percentage'' means, for the small group 
     market or individual market in a State for a year, such 
     percentage as determined in accordance with the following 
     table based on the State's premium performance level (as 
     defined in subparagraph (B)) for such market and year:


----------------------------------------------------------------------------------------------------------------
   The bonus
    premium        For year 3 if the premium        For year 6 if the premium        For year 9 if the premium
percentage for   performance level of the State   performance level of the State  performance level of the State
 a State is--                 is--                             is--                            is--
----------------------------------------------------------------------------------------------------------------
  100 percent   at least 8.5%                    at least 11%                     at least 13.5%
----------------------------------------------------------------------------------------------------------------
   50 percent   at least 6.38%, but less than    at least 10.38%, but less than   at least 12.88%, but less than
                 8.5%                             11%                              13.5%
----------------------------------------------------------------------------------------------------------------
   25 percent   at least 4.25%, but less than     at least 9.75%, but less than   at least 12.25%, but less than
                 6.38%                            10.38%                           12.88%
----------------------------------------------------------------------------------------------------------------
    0 percent   less than 4.25%                  less than 9.75%                  less than 12.25%
----------------------------------------------------------------------------------------------------------------

       (B) Premium performance level.--For purposes of this 
     subsection, the term ``premium performance level'' means, for 
     a State, market, and year, the percentage reduction in the 
     average per capita premiums for health insurance coverage for 
     the State, market, and year, as compared to the premium 
     baseline for such State, market, and year.
       (4) Maximum state premium payment amount defined.--For 
     purposes of this subsection, the term ``maximum State premium 
     payment amount'' means, for a State for the small group 
     market or the individual market for a year, the product of--
       (A) the proportion (as determined by the Secretary), of the 
     number of nonelderly individuals lawfully residing in all the 
     States who are enrolled in health insurance coverage in the 
     respective market in the year, who are residents of the 
     State; and
       (B) the amount available for obligation from amounts 
     appropriated under subsection (d) for such market with 
     respect to performance in such year.
       (5) Methodology for calculating average per capita 
     premiums.--
       (A) Establishment.--The Secretary shall establish, by rule 
     and consistent with this subsection, a methodology for 
     computing the average per capita premiums for health 
     insurance coverage for the small group market and for the 
     individual market in each State for each year beginning with 
     year 1.
       (B) Adjustments.--Under such methodology, the Secretary 
     shall provide for the following adjustments (in a manner 
     determined appropriate by the Secretary):
       (i) Exclusion of illegal aliens.--An adjustment so as not 
     to take into account enrollees who are not lawfully present 
     in the United States and their premium costs.
       (ii) Treating state premium subsidies as premium costs.--An 
     adjustment so as to increase per capita premiums to remove 
     the impact of premium subsidies made directly by a State to 
     reduce health insurance premiums.
       (6) Conditions of payment.--As a condition of receiving a 
     payment under paragraph (1), a State must agree to submit 
     aggregate, non-individually identifiable data to the 
     Secretary, in a form and manner specified by the Secretary, 
     for use by the Secretary to determine the State's premium 
     baseline and premium performance level for purposes of this 
     subsection.
       (b) Programs That Reduce the Number of Uninsured.--
       (1) In general.--If the Secretary determines that a State 
     has reduced the percentage of uninsured nonelderly residents 
     in year 5, year 7, or year 9, below the uninsured baseline 
     (as defined in paragraph (2)) for the State for the year, the 
     Secretary shall pay the State an amount equal to the product 
     of--
       (A) bonus uninsured percentage (as defined in paragraph 
     (3)) for the State and year; and
       (B) the maximum uninsured payment amount (as defined in 
     paragraph (4)) for the State and year.
       (2) Uninsured baseline.--
       (A) In general.--For purposes of this subsection, and 
     subject to subparagraph (B), the term ``uninsured baseline'' 
     means, for a State, the percentage of nonelderly residents in 
     the State who are uninsured in year 1.
       (B) Adjustment.--The Secretary may, at the written request 
     of a State, adjust the uninsured baseline for States for a 
     year to take into account unanticipated and exceptional 
     changes, such as an unanticipated migration, of nonelderly 
     individuals into, or out of, States in a manner that does not 
     reflect substantially the proportion of uninsured nonelderly 
     residents in the States involved in year 1. Any such 
     adjustment shall only be done in a manner that does not 
     result in the average of the uninsured baselines for 
     nonelderly residents for all States being changed.
       (3) Bonus uninsured percentage.--
       (A) Bonus uninsured percentage.--For purposes of this 
     subsection, the term ``bonus uninsured percentage'' means, 
     for a State for a year, such percentage as determined in 
     accordance with the following table, based on the uninsured 
     performance level (as defined in subparagraph (B)) for such 
     State and year:


----------------------------------------------------------------------------------------------------------------
   The bonus
   uninsured      For year 5 if the uninsured      For year 7 if the uninsured      For year 9 if the uninsured
percentage for   performance level of the State   performance level of the State  performance level of the State
 a State is--                 is--                             is--                            is--
----------------------------------------------------------------------------------------------------------------
  100 percent   at least 10%                     at least 15%                     at least 20%
----------------------------------------------------------------------------------------------------------------
   50 percent   at least 7.5% but less than 10%  at least 13.75% but less than    at least 18.75% but less than
                                                  15%                              20%
----------------------------------------------------------------------------------------------------------------
   25 percent   at least 5% but less than 7.5%   at least 12.5% but less than     at least 17.5% but less than
                                                  13.75%                           18.75%
----------------------------------------------------------------------------------------------------------------
    0 percent   less than 5%                     less than 12.5%                  less than 17.5%
----------------------------------------------------------------------------------------------------------------


[[Page 27536]]

       (B) Uninsured performance level.--For purposes of this 
     subsection, the term ``uninsured performance level'' means, 
     for a State for a year, the reduction (expressed as a 
     percentage) in the percentage of uninsured nonelderly 
     residents in such State in the year as compared to the 
     uninsured baseline for such State for such year.
       (4) Maximum state uninsured payment amount defined.--For 
     purposes of this subsection, the term ``maximum State 
     uninsured payment amount'' means, for a State for a year, the 
     product of--
       (A) the proportion (as determined by the Secretary), of the 
     number of uninsured nonelderly individuals lawfully residing 
     in all the States in the year, who are residents of the 
     State; and
       (B) the amount available for obligation under this 
     subsection from amounts appropriated under subsection (d) 
     with respect to performance in such year.
       (5) Methodology for computing the percentage of uninsured 
     nonelderly residents in a state.--
       (A) Establishment.--The Secretary shall establish, by rule 
     and consistent with this subsection, a methodology for 
     computing the percentage of nonelderly residents in a State 
     who are uninsured in each year beginning with year 1.
       (B) Rules.--
       (i) Treatment of uninsured.--Such methodology shall treat 
     as uninsured those residents who do not have health insurance 
     coverage or other creditable coverage (as defined in section 
     9801(c)(1) of the Internal Revenue Code of 1986), except that 
     such methodology shall rely upon data on the nonelderly and 
     uninsured populations within each State in such year provided 
     through population surveys conducted by federal agencies.
       (ii) Limitation to nonelderly.--Such methodology shall 
     exclude individuals who are 65 years of age or older.
       (iii) Exclusion of illegal aliens.--Such methodology shall 
     exclude individuals not lawfully present in the United 
     States.
       (6) Conditions of payment.--As a condition of receiving a 
     payment under paragraph (1), a State must agree to submit 
     aggregate, non-individually identifiable data to the 
     Secretary, in a form and manner specified by the Secretary, 
     for use by the Secretary in determining the State's uninsured 
     baseline and uninsured performance level for purposes of this 
     subsection.
       (c) Definitions.--For purposes of this section:
       (1) Group health plan.--The term ``group health plan'' has 
     the meaning given such term in section 9832(a) of the 
     Internal Revenue Code of 1986.
       (2) Health insurance coverage.--The term ``health insurance 
     coverage'' has the meaning given such term in section 
     9832(b)(1) of the Internal Revenue Code of 1986.
       (3) Individual market.--Except as the Secretary may 
     otherwise provide in the case of group health plans that have 
     fewer than 2 participants as current employees on the first 
     day of a plan year, the term ``individual market'' means the 
     market for health insurance coverage offered to individuals 
     other than in connection with a group health plan.
       (4) Secretary.--The term ``Secretary'' means the Secretary 
     of Health and Human Services.
       (5) Small group market.--The term ``small group market'' 
     means the market for health insurance coverage under which 
     individuals obtain health insurance coverage (directly or 
     through any arrangement) on behalf of themselves (and their 
     dependents) through a group health plan maintained by an 
     employer who employed on average at least 2 but not more than 
     50 employees on business days during a calendar year.
       (6) State.--The term ``State'' means any of the 50 States 
     and the District of Columbia.
       (7) Years.--The terms ``year 1'', ``year 2'', ``year 3'', 
     and similar subsequently numbered years mean 2010, 2011, 
     2012, and subsequent sequentially numbered years.
       (d) Appropriations; Payments.--
       (1) Payments for reductions in cost of health insurance 
     coverage.--
       (A) Small group market.--
       (i) In general.--From any funds in the Treasury not 
     otherwise appropriated, there is appropriated for payments 
     under subsection (a)(1)(A)--

       (I) $18,000,000,000 with respect to performance in year 3;
       (II) $5,000,000,000 with respect to performance in year 6; 
     and
       (III) $2,000,000,000 with respect to performance in year 9.

       (ii) Availability of appropriated funds.--Funds 
     appropriated under clause (i) shall remain available until 
     expended.
       (B) Individual market.--
       (i) In general.--Subject to clause (ii), from any funds in 
     the Treasury not otherwise appropriated, there is 
     appropriated for payments under subsection (a)(1)(B)--

       (I) $7,000,000,000 with respect to performance in year 3;
       (II) $2,000,000,000 with respect to performance in year 6; 
     and
       (III) $1,000,000,000 with respect to performance in year 9.

       (ii) Availability of appropriated funds.--Of the funds 
     appropriated under clause (i) that are not expended or 
     obligated by the end of the year following the year for which 
     the funds are appropriated--

       (I) 75 percent shall remain available until expended for 
     payments under subsection (a)(1)(B); and
       (II) 25 percent shall remain available until expended for 
     payments under subsection (a)(1)(A).

       (2) Payments for reductions in the percentage of 
     uninsured.--
       (A) In general.--From any funds in the Treasury not 
     otherwise appropriated, there is appropriated for payments 
     under subsection (b)(1)--
       (i) $10,000,000,000 with respect to performance in year 5;
       (ii) $3,000,000,000 with respect to performance in year 7; 
     and
       (iii) $2,000,000,000 with respect to performance in year 9
       (B) Availability of appropriated funds.--Funds appropriated 
     under subparagraph (A) shall remain available until expended.
       (3) Payment timing.--Payments under this section shall be 
     made in a form and manner specified by the Secretary in the 
     year after the performance year involved.

     SEC. 112. HEALTH PLAN FINDERS.

       (a) State Plan Finders.--Not later than 12 months after the 
     date of the enactment of this Act, each State may contract 
     with a private entity to develop and operate a plan finder 
     website (referred to in this section as a ``State plan 
     finder'') which shall provide information to individuals in 
     such State on plans of health insurance coverage that are 
     available to individuals in such State (in this section 
     referred to as a ``health insurance plan''). Such State may 
     not operate a plan finder itself.
       (b) Multi-State Plan Finders.--
       (1) In general.--A private entity may operate a multi-State 
     finder that operates under this section in the States 
     involved in the same manner as a State plan finder would 
     operate in a single State.
       (2) Sharing of information.--States shall regulate the 
     manner in which data is shared between plan finders to ensure 
     consistency and accuracy in the information about health 
     insurance plans contained in such finders.
       (c) Requirements for Plan Finders.--Each plan finder shall 
     meet the following requirements:
       (1) The plan finder shall ensure that each health insurance 
     plan in the plan finder meets the requirements for such plans 
     under subsection (d).
       (2) The plan finder shall present complete information on 
     the costs and benefits of health insurance plans (including 
     information on monthly premium, copayments, and deductibles) 
     in a uniform manner that--
       (A) uses the standard definitions developed under paragraph 
     (3); and
       (B) is designed to allow consumers to easily compare such 
     plans.
       (3) The plan finder shall be available on the internet and 
     accessible to all individuals in the State or, in the case of 
     a multi-State plan finder, in all States covered by the 
     multi-State plan finder.
       (4) The plan finder shall allow consumers to search and 
     sort data on the health insurance plans in the plan finder on 
     criteria such as coverage of specific benefits (such as 
     coverage of disease management services or pediatric care 
     services), as well as data available on quality.
       (5) The plan finder shall meet all relevant State laws and 
     regulations, including laws and regulations related to the 
     marketing of insurance products. In the case of a multi-State 
     plan finder, the finder shall meet such laws and regulations 
     for all of the States involved.
       (6) The plan finder shall meet solvency, financial, and 
     privacy requirements established by the State or States in 
     which the plan finder operates or the Secretary for multi-
     State finders.
       (7) The plan finder and the employees of the plan finder 
     shall be appropriately licensed in the State or States in 
     which the plan finder operates, if such licensure is required 
     by such State or States.
       (8) Notwithstanding subsection (f)(1), the plan finder 
     shall assist individuals who are eligible for the Medicaid 
     program under title XIX of the Social Security Act or State 
     Children's Health Insurance Program under title XXI of such 
     Act by including information on Medicaid options, 
     eligibility, and how to enroll.
       (d) Requirements for Plans Participating in a Plan 
     Finder.--
       (1) In general.--Each State shall ensure that health 
     insurance plans participating in the State plan finder or in 
     a multi-State plan finder meet the requirements of paragraph 
     (2) (relating to adequacy of insurance coverage, consumer 
     protection, and financial strength).
       (2) Specific requirements.--In order to participate in a 
     plan finder, a health insurance plan must meet all of the 
     following requirements, as determined by each State in which 
     such plan operates:
       (A) The health insurance plan shall be actuarially sound.
       (B) The health insurance plan may not have a history of 
     abusive policy rescissions.
       (C) The health insurance plan shall meet financial and 
     solvency requirements.
       (D) The health insurance plan shall disclose--

[[Page 27537]]

       (i) all financial arrangements involving the sale and 
     purchase of health insurance, such as the payment of fees and 
     commissions; and
       (ii) such arrangements may not be abusive.
       (E) The health insurance plan shall maintain electronic 
     health records that comply with the requirements of the 
     American Recovery and Reinvestment Act of 2009 (Public Law 
     111-5) related to electronic health records.
       (F) The health insurance plan shall make available to plan 
     enrollees via the finder, whether by information provided to 
     the finder or by a website link directing the enrollee from 
     the finder to the health insurance plan website, data that 
     includes the price and cost to the individual of services 
     offered by a provider according to the terms and conditions 
     of the health plan. Data described in this paragraph is not 
     made public by the finder, only made available to the 
     individual once enrolled in the health plan.
       (e) Prohibitions.--
       (1) Direct enrollment.--The State plan finder may not 
     directly enroll individuals in health insurance plans.
       (2) Conflicts of interest.--
       (A) Companies.--A health insurance issuer offering a health 
     insurance plan through a plan finder may not--
       (i) be the private entity developing and maintaining a plan 
     finder under subsections (a) and (b); or
       (ii) have an ownership interest in such private entity or 
     in the plan finder.
       (B) Individuals.--An individual employed by a health 
     insurance issuer offering a health insurance plan through a 
     plan finder may not serve as a director or officer for--
       (i) the private entity developing and maintaining a plan 
     finder under subsections (a) and (b); or
       (ii) the plan finder.
       (f) Construction.--Nothing in this section shall be 
     construed to allow the Secretary authority to regulate 
     benefit packages or to prohibit health insurance brokers and 
     agents from--
       (1) utilizing the plan finder for any purpose; or
       (2) marketing or offering health insurance products.
       (g) Plan Finder Defined.--For purposes of this section, the 
     term ``plan finder'' means a State plan finder under 
     subsection (a) or a multi-State plan finder under subsection 
     (b).
       (h) State Defined.--In this section, the term ``State'' has 
     the meaning given such term for purposes of title XIX of the 
     Social Security Act.

     SEC. 113. ADMINISTRATIVE SIMPLIFICATION.

       (a) Operating Rules for Health Information Transactions.--
       (1) Definition of operating rules.--Section 1171 of the 
     Social Security Act (42 U.S.C. 1320d) is amended by adding at 
     the end the following:
       ``(9) Operating rules.--The term `operating rules' means 
     the necessary business rules and guidelines for the 
     electronic exchange of information that are not defined by a 
     standard or its implementation specifications as adopted for 
     purposes of this part.''.
       (2) Operating rules and compliance.--Section 1173 of the 
     Social Security Act (42 U.S.C. 1320d-2) is amended--
       (A) in subsection (a)(2), by adding at the end the 
     following new subparagraph:
       ``(J) Electronic funds transfers.''; and
       (B) by adding at the end the following new subsections:
       ``(g) Operating Rules.--
       ``(1) In general.--The Secretary shall adopt a single set 
     of operating rules for each transaction described in 
     subsection (a)(2) with the goal of creating as much 
     uniformity in the implementation of the electronic standards 
     as possible. Such operating rules shall be consensus-based 
     and reflect the necessary business rules affecting health 
     plans and health care providers and the manner in which they 
     operate pursuant to standards issued under Health Insurance 
     Portability and Accountability Act of 1996.
       ``(2) Operating rules development.--In adopting operating 
     rules under this subsection, the Secretary shall rely on 
     recommendations for operating rules developed by a qualified 
     nonprofit entity, as selected by the Secretary, that meets 
     the following requirements:
       ``(A) The entity focuses its mission on administrative 
     simplification.
       ``(B) The entity demonstrates an established multi-
     stakeholder and consensus-based process for development of 
     operating rules, including representation by or participation 
     from health plans, health care providers, vendors, relevant 
     Federal agencies, and other standard development 
     organizations.
       ``(C) The entity has established a public set of guiding 
     principles that ensure the operating rules and process are 
     open and transparent.
       ``(D) The entity coordinates its activities with the HIT 
     Policy Committee and the HIT Standards Committee (as 
     established under title XXX of the Public Health Service Act) 
     and complements the efforts of the Office of the National 
     Healthcare Coordinator and its related health information 
     exchange goals.
       ``(E) The entity incorporates national standards, including 
     the transaction standards issued under Health Insurance 
     Portability and Accountability Act of 1996.
       ``(F) The entity supports nondiscrimination and conflict of 
     interest policies that demonstrate a commitment to open, 
     fair, and nondiscriminatory practices.
       ``(G) The entity allows for public review and updates of 
     the operating rules.
       ``(3) Review and recommendations.--The National Committee 
     on Vital and Health Statistics shall--
       ``(A) review the operating rules developed by a nonprofit 
     entity described under paragraph (2);
       ``(B) determine whether such rules represent a consensus 
     view of the health care industry and are consistent with and 
     do not alter current standards;
       ``(C) evaluate whether such rules are consistent with 
     electronic standards adopted for health information 
     technology; and
       ``(D) submit to the Secretary a recommendation as to 
     whether the Secretary should adopt such rules.
       ``(4) Implementation.--
       ``(A) In general.--The Secretary shall adopt operating 
     rules under this subsection, by regulation in accordance with 
     subparagraph (C), following consideration of the rules 
     developed by the non-profit entity described in paragraph (2) 
     and the recommendation submitted by the National Committee on 
     Vital and Health Statistics under paragraph (3)(D) and having 
     ensured consultation with providers.
       ``(B) Adoption requirements; effective dates.--
       ``(i) Eligibility for a health plan and health claim 
     status.--The set of operating rules for transactions for 
     eligibility for a health plan and health claim status shall 
     be adopted not later than July 1, 2011, in a manner ensuring 
     that such rules are effective not later than January 1, 2013, 
     and may allow for the use of a machine readable 
     identification card.
       ``(ii) Electronic funds transfers and health care payment 
     and remittance advice.--The set of operating rules for 
     electronic funds transfers and health care payment and 
     remittance advice shall be adopted not later than July 1, 
     2012, in a manner ensuring that such rules are effective not 
     later than January 1, 2014.
       ``(iii) Other completed transactions.--The set of operating 
     rules for the remainder of the completed transactions 
     described in subsection (a)(2), including health claims or 
     equivalent encounter information, enrollment and 
     disenrollment in a health plan, health plan premium payments, 
     and referral certification and authorization, shall be 
     adopted not later than July 1, 2014, in a manner ensuring 
     that such rules are effective not later than January 1, 2016.
       ``(C) Expedited rulemaking.--The Secretary shall promulgate 
     an interim final rule applying any standard or operating rule 
     recommended by the National Committee on Vital and Health 
     Statistics pursuant to paragraph (3). The Secretary shall 
     accept public comments on any interim final rule published 
     under this subparagraph for 60 days after the date of such 
     publication.
       ``(h) Compliance.--
       ``(1) Health plan certification.--
       ``(A) Eligibility for a health plan, health claim status, 
     electronic funds transfers, health care payment and 
     remittance advice.--Not later than December 31, 2013, a 
     health plan shall file a statement with the Secretary, in 
     such form as the Secretary may require, certifying that the 
     data and information systems for such plan are in compliance 
     with any applicable standards (as described under paragraph 
     (7) of section 1171) and operating rules (as described under 
     paragraph (9) of such section) for electronic funds 
     transfers, eligibility for a health plan, health claim 
     status, and health care payment and remittance advice, 
     respectively.
       ``(B) Other completed transactions.--Not later than 
     December 31, 2015, a health plan shall file a statement with 
     the Secretary, in such form as the Secretary may require, 
     certifying that the data and information systems for such 
     plan are in compliance with any applicable standards and 
     operating rules for the remainder of the completed 
     transactions described in subsection (a)(2), including health 
     claims or equivalent encounter information, enrollment and 
     disenrollment in a health plan, health plan premium payments, 
     and referral certification and authorization, respectively. A 
     health plan shall provide the same level of documentation to 
     certify compliance with such transactions as is required to 
     certify compliance with the transactions specified in 
     subparagraph (A).
       ``(2) Documentation of compliance.--A health plan shall 
     provide the Secretary, in such form as the Secretary may 
     require, with adequate documentation of compliance with the 
     standards and operating rules described under paragraph (1). 
     A health plan shall not be considered to have provided 
     adequate documentation and shall not be certified as being in 
     compliance with such standards, unless the health plan--
       ``(A) demonstrates to the Secretary that the plan conducts 
     the electronic transactions specified in paragraph (1) in a 
     manner that fully complies with the regulations of the 
     Secretary; and
       ``(B) provides documentation showing that the plan has 
     completed end-to-end testing for such transactions with their 
     partners, such as hospitals and physicians.

[[Page 27538]]

       ``(3) Service contracts.--A health plan shall be required 
     to comply with any applicable certification and compliance 
     requirements (and provide the Secretary with adequate 
     documentation of such compliance) under this subsection for 
     any entities that provide services pursuant to a contract 
     with such health plan.
       ``(4) Certification by outside entity.--The Secretary may 
     contract with an independent, outside entity to certify that 
     a health plan has complied with the requirements under this 
     subsection, provided that the certification standards 
     employed by such entities are in accordance with any 
     standards or rules issued by the Secretary.
       ``(5) Compliance with revised standards and rules.--A 
     health plan (including entities described under paragraph 
     (3)) shall comply with the certification and documentation 
     requirements under this subsection for any interim final rule 
     promulgated by the Secretary under subsection (i) that amends 
     any standard or operating rule described under paragraph (1) 
     of this subsection. A health plan shall comply with such 
     requirements not later than the effective date of the 
     applicable interim final rule.
       ``(6) Audits of health plans.--The Secretary shall conduct 
     periodic audits to ensure that health plans (including 
     entities described under paragraph (3)) are in compliance 
     with any standards and operating rules that are described 
     under paragraph (1).
       ``(i) Review and Amendment of Standards and Rules.--
       ``(1) Establishment.--Not later than January 1, 2014, the 
     Secretary shall establish a review committee (as described 
     under paragraph (4)).
       ``(2) Evaluations and reports.--
       ``(A) Hearings.--Not later than April 1, 2014, and not less 
     than biennially thereafter, the Secretary, acting through the 
     review committee, shall conduct hearings to evaluate and 
     review the existing standards and operating rules established 
     under this section.
       ``(B) Report.--Not later than July 1, 2014, and not less 
     than biennially thereafter, the review committee shall 
     provide recommendations for updating and improving such 
     standards and rules. The review committee shall recommend a 
     single set of operating rules per transaction standard and 
     maintain the goal of creating as much uniformity as possible 
     in the implementation of the electronic standards.
       ``(3) Interim final rulemaking.--
       ``(A) In general.--Any recommendations to amend existing 
     standards and operating rules that have been approved by the 
     review committee and reported to the Secretary under 
     paragraph (2)(B) shall be adopted by the Secretary through 
     promulgation of an interim final rule not later than 90 days 
     after receipt of the committee's report.
       ``(B) Public comment.--
       ``(i) Public comment period.--The Secretary shall accept 
     public comments on any interim final rule published under 
     this paragraph for 60 days after the date of such 
     publication.
       ``(ii) Effective date.--The effective date of any amendment 
     to existing standards or operating rules that is adopted 
     through an interim final rule published under this paragraph 
     shall be 25 months following the close of such public comment 
     period.
       ``(4) Review committee.--
       ``(A) Definition.--For the purposes of this subsection, the 
     term `review committee' means a committee within the 
     Department of Health and Human services that has been 
     designated by the Secretary to carry out this subsection, 
     including--
       ``(i) the National Committee on Vital and Health 
     Statistics; or
       ``(ii) any appropriate committee as determined by the 
     Secretary.
       ``(B) Coordination of hit standards.--In developing 
     recommendations under this subsection, the review committee 
     shall consider the standards approved by the Office of the 
     National Coordinator for Health Information Technology.
       ``(j) Penalties.--
       ``(1) Penalty fee.--
       ``(A) In general.--Not later than April 1, 2014, and 
     annually thereafter, the Secretary shall assess a penalty fee 
     (as determined under subparagraph (B)) against a health plan 
     that has failed to meet the requirements under subsection (h) 
     with respect to certification and documentation of compliance 
     with the standards (and their operating rules) as described 
     under paragraph (1) of such subsection.
       ``(B) Fee amount.--Subject to subparagraphs (C), (D), and 
     (E), the Secretary shall assess a penalty fee against a 
     health plan in the amount of $1 per covered life until 
     certification is complete. The penalty shall be assessed per 
     person covered by the plan for which its data systems for 
     major medical policies are not in compliance and shall be 
     imposed against the health plan for each day that the plan is 
     not in compliance with the requirements under subsection (h).
       ``(C) Additional penalty for misrepresentation.--A health 
     plan that knowingly provides inaccurate or incomplete 
     information in a statement of certification or documentation 
     of compliance under subsection (h) shall be subject to a 
     penalty fee that is double the amount that would otherwise be 
     imposed under this subsection.
       ``(D) Annual fee increase.--The amount of the penalty fee 
     imposed under this subsection shall be increased on an annual 
     basis by the annual percentage increase in total national 
     health care expenditures, as determined by the Secretary.
       ``(E) Penalty limit.--A penalty fee assessed against a 
     health plan under this subsection shall not exceed, on an 
     annual basis--
       ``(i) an amount equal to $20 per covered life under such 
     plan; or
       ``(ii) an amount equal to $40 per covered life under the 
     plan if such plan has knowingly provided inaccurate or 
     incomplete information (as described under subparagraph (C)).
       ``(F) Determination of covered individuals.--The Secretary 
     shall determine the number of covered lives under a health 
     plan based upon the most recent statements and filings that 
     have been submitted by such plan to the Securities and 
     Exchange Commission.
       ``(2) Notice and dispute procedure.--The Secretary shall 
     establish a procedure for assessment of penalty fees under 
     this subsection that provides a health plan with reasonable 
     notice and a dispute resolution procedure prior to provision 
     of a notice of assessment by the Secretary of the Treasury 
     (as described under paragraph (4)(B)).
       ``(3) Penalty fee report.--Not later than May 1, 2014, and 
     annually thereafter, the Secretary shall provide the 
     Secretary of the Treasury with a report identifying those 
     health plans that have been assessed a penalty fee under this 
     subsection.
       ``(4) Collection of penalty fee.--
       ``(A) In general.--The Secretary of the Treasury, acting 
     through the Financial Management Service, shall administer 
     the collection of penalty fees from health plans that have 
     been identified by the Secretary in the penalty fee report 
     provided under paragraph (3).
       ``(B) Notice.--Not later than August 1, 2014, and annually 
     thereafter, the Secretary of the Treasury shall provide 
     notice to each health plan that has been assessed a penalty 
     fee by the Secretary under this subsection. Such notice shall 
     include the amount of the penalty fee assessed by the 
     Secretary and the due date for payment of such fee to the 
     Secretary of the Treasury (as described in subparagraph (C)).
       ``(C) Payment due date.--Payment by a health plan for a 
     penalty fee assessed under this subsection shall be made to 
     the Secretary of the Treasury not later than November 1, 
     2014, and annually thereafter.
       ``(D) Unpaid penalty fees.--Any amount of a penalty fee 
     assessed against a health plan under this subsection for 
     which payment has not been made by the due date provided 
     under subparagraph (C) shall be--
       ``(i) increased by the interest accrued on such amount, as 
     determined pursuant to the underpayment rate established 
     under section 6601 of the Internal Revenue Code of 1986; and
       ``(ii) treated as a past-due, legally enforceable debt owed 
     to a Federal agency for purposes of section 6402(d) of the 
     Internal Revenue Code of 1986.
       ``(E) Administrative fees.--Any fee charged or allocated 
     for collection activities conducted by the Financial 
     Management Service will be passed on to a health plan on a 
     pro-rata basis and added to any penalty fee collected from 
     the plan.''.
       (b) Promulgation of Rules.--
       (1) Unique health plan identifier.--The Secretary shall 
     promulgate a final rule to establish a unique health plan 
     identifier (as described in section 1173(b) of the Social 
     Security Act (42 U.S.C. 1320d-2(b))) based on the input of 
     the National Committee of Vital and Health Statistics. The 
     Secretary may do so on an interim final basis and such rule 
     shall be effective not later than October 1, 2012.
       (2) Electronic funds transfer.--The Secretary shall 
     promulgate a final rule to establish a standard for 
     electronic funds transfers (as described in section 
     1173(a)(2)(J) of the Social Security Act, as added by 
     subsection (a)(2)(A)). The Secretary may do so on an interim 
     final basis and shall adopt such standard not later than 
     January 1, 2012, in a manner ensuring that such standard is 
     effective not later than January 1, 2014.
       (c) Expansion of Electronic Transactions in Medicare.--
     Section 1862(a) of the Social Security Act (42 U.S.C. 
     1395y(a)) is amended--
       (1) in paragraph (23), by striking the ``or'' at the end;
       (2) in paragraph (24), by striking the period and inserting 
     ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) not later than January 1, 2014, for which the 
     payment is other than by electronic funds transfer (EFT) or 
     an electronic remittance in a form as specified in ASC X12 
     835 Health Care Payment and Remittance Advice or subsequent 
     standard.''.
       (d) Medicare and Medicaid Compliance Reports.--Not later 
     than July 1, 2013, the Secretary of Health and Human Services 
     shall submit a report to the Chairs and Ranking Members of 
     the Committee on Ways and Means and the Committee on Energy 
     and Commerce of the House of Representatives and the Chairs 
     and Ranking Members of the Committee on Health, Education, 
     Labor, and Pensions and the Committee on

[[Page 27539]]

     Finance of the Senate on the extent to which the Medicare 
     program and providers that serve beneficiaries under that 
     program, and State Medicaid programs and providers that serve 
     beneficiaries under those programs, transact electronically 
     in accordance with transaction standards issued under the 
     Health Insurance Portability and Accountability Act of 1996, 
     part C of title XI of the Social Security Act, and 
     regulations promulgated under such Acts.

              DIVISION B--IMPROVING ACCESS TO HEALTH CARE

   TITLE I--EXPANDING ACCESS AND LOWERING COSTS FOR SMALL BUSINESSES

     SEC. 201. RULES GOVERNING ASSOCIATION HEALTH PLANS.

       (a) In General.--Subtitle B of title I of the Employee 
     Retirement Income Security Act of 1974 is amended by adding 
     after part 7 the following new part:

           ``PART 8--RULES GOVERNING ASSOCIATION HEALTH PLANS

     ``SEC. 801. ASSOCIATION HEALTH PLANS.

       ``(a) In General.--For purposes of this part, the term 
     `association health plan' means a group health plan whose 
     sponsor is (or is deemed under this part to be) described in 
     subsection (b).
       ``(b) Sponsorship.--The sponsor of a group health plan is 
     described in this subsection if such sponsor--
       ``(1) is organized and maintained in good faith, with a 
     constitution and bylaws specifically stating its purpose and 
     providing for periodic meetings on at least an annual basis, 
     as a bona fide trade association, a bona fide industry 
     association (including a rural electric cooperative 
     association or a rural telephone cooperative association), a 
     bona fide professional association, or a bona fide chamber of 
     commerce (or similar bona fide business association, 
     including a corporation or similar organization that operates 
     on a cooperative basis (within the meaning of section 1381 of 
     the Internal Revenue Code of 1986)), for substantial purposes 
     other than that of obtaining or providing medical care;
       ``(2) is established as a permanent entity which receives 
     the active support of its members and requires for membership 
     payment on a periodic basis of dues or payments necessary to 
     maintain eligibility for membership in the sponsor; and
       ``(3) does not condition membership, such dues or payments, 
     or coverage under the plan on the basis of health status-
     related factors with respect to the employees of its members 
     (or affiliated members), or the dependents of such employees, 
     and does not condition such dues or payments on the basis of 
     group health plan participation.

     Any sponsor consisting of an association of entities which 
     meet the requirements of paragraphs (1), (2), and (3) shall 
     be deemed to be a sponsor described in this subsection.

     ``SEC. 802. CERTIFICATION OF ASSOCIATION HEALTH PLANS.

       ``(a) In General.--The applicable authority shall prescribe 
     by regulation a procedure under which, subject to subsection 
     (b), the applicable authority shall certify association 
     health plans which apply for certification as meeting the 
     requirements of this part.
       ``(b) Standards.--Under the procedure prescribed pursuant 
     to subsection (a), in the case of an association health plan 
     that provides at least one benefit option which does not 
     consist of health insurance coverage, the applicable 
     authority shall certify such plan as meeting the requirements 
     of this part only if the applicable authority is satisfied 
     that the applicable requirements of this part are met (or, 
     upon the date on which the plan is to commence operations, 
     will be met) with respect to the plan.
       ``(c) Requirements Applicable to Certified Plans.--An 
     association health plan with respect to which certification 
     under this part is in effect shall meet the applicable 
     requirements of this part, effective on the date of 
     certification (or, if later, on the date on which the plan is 
     to commence operations).
       ``(d) Requirements for Continued Certification.--The 
     applicable authority may provide by regulation for continued 
     certification of association health plans under this part.
       ``(e) Class Certification for Fully Insured Plans.--The 
     applicable authority shall establish a class certification 
     procedure for association health plans under which all 
     benefits consist of health insurance coverage. Under such 
     procedure, the applicable authority shall provide for the 
     granting of certification under this part to the plans in 
     each class of such association health plans upon appropriate 
     filing under such procedure in connection with plans in such 
     class and payment of the prescribed fee under section 807(a).
       ``(f) Certification of Self-Insured Association Health 
     Plans.--An association health plan which offers one or more 
     benefit options which do not consist of health insurance 
     coverage may be certified under this part only if such plan 
     consists of any of the following:
       ``(1) a plan which offered such coverage on the date of the 
     enactment of the Small Business Health Fairness Act of 2009,
       ``(2) a plan under which the sponsor does not restrict 
     membership to one or more trades and businesses or industries 
     and whose eligible participating employers represent a broad 
     cross-section of trades and businesses or industries, or
       ``(3) a plan whose eligible participating employers 
     represent one or more trades or businesses, or one or more 
     industries, consisting of any of the following: agriculture; 
     equipment and automobile dealerships; barbering and 
     cosmetology; certified public accounting practices; child 
     care; construction; dance, theatrical and orchestra 
     productions; disinfecting and pest control; financial 
     services; fishing; food service establishments; hospitals; 
     labor organizations; logging; manufacturing (metals); mining; 
     medical and dental practices; medical laboratories; 
     professional consulting services; sanitary services; 
     transportation (local and freight); warehousing; wholesaling/
     distributing; or any other trade or business or industry 
     which has been indicated as having average or above-average 
     risk or health claims experience by reason of State rate 
     filings, denials of coverage, proposed premium rate levels, 
     or other means demonstrated by such plan in accordance with 
     regulations.

     ``SEC. 803. REQUIREMENTS RELATING TO SPONSORS AND BOARDS OF 
                   TRUSTEES.

       ``(a) Sponsor.--The requirements of this subsection are met 
     with respect to an association health plan if the sponsor has 
     met (or is deemed under this part to have met) the 
     requirements of section 801(b) for a continuous period of not 
     less than 3 years ending with the date of the application for 
     certification under this part.
       ``(b) Board of Trustees.--The requirements of this 
     subsection are met with respect to an association health plan 
     if the following requirements are met:
       ``(1) Fiscal control.--The plan is operated, pursuant to a 
     trust agreement, by a board of trustees which has complete 
     fiscal control over the plan and which is responsible for all 
     operations of the plan.
       ``(2) Rules of operation and financial controls.--The board 
     of trustees has in effect rules of operation and financial 
     controls, based on a 3-year plan of operation, adequate to 
     carry out the terms of the plan and to meet all requirements 
     of this title applicable to the plan.
       ``(3) Rules governing relationship to participating 
     employers and to contractors.--
       ``(A) Board membership.--
       ``(i) In general.--Except as provided in clauses (ii) and 
     (iii), the members of the board of trustees are individuals 
     selected from individuals who are the owners, officers, 
     directors, or employees of the participating employers or who 
     are partners in the participating employers and actively 
     participate in the business.
       ``(ii) Limitation.--

       ``(I) General rule.--Except as provided in subclauses (II) 
     and (III), no such member is an owner, officer, director, or 
     employee of, or partner in, a contract administrator or other 
     service provider to the plan.
       ``(II) Limited exception for providers of services solely 
     on behalf of the sponsor.--Officers or employees of a sponsor 
     which is a service provider (other than a contract 
     administrator) to the plan may be members of the board if 
     they constitute not more than 25 percent of the membership of 
     the board and they do not provide services to the plan other 
     than on behalf of the sponsor.
       ``(III) Treatment of providers of medical care.--In the 
     case of a sponsor which is an association whose membership 
     consists primarily of providers of medical care, subclause 
     (I) shall not apply in the case of any service provider 
     described in subclause (I) who is a provider of medical care 
     under the plan.

       ``(iii) Certain plans excluded.--Clause (i) shall not apply 
     to an association health plan which is in existence on the 
     date of the enactment of the Small Business Health Fairness 
     Act of 2009.
       ``(B) Sole authority.--The board has sole authority under 
     the plan to approve applications for participation in the 
     plan and to contract with a service provider to administer 
     the day-to-day affairs of the plan.
       ``(c) Treatment of Franchise Networks.--In the case of a 
     group health plan which is established and maintained by a 
     franchiser for a franchise network consisting of its 
     franchisees--
       ``(1) the requirements of subsection (a) and section 801(a) 
     shall be deemed met if such requirements would otherwise be 
     met if the franchiser were deemed to be the sponsor referred 
     to in section 801(b), such network were deemed to be an 
     association described in section 801(b), and each franchisee 
     were deemed to be a member (of the association and the 
     sponsor) referred to in section 801(b); and
       ``(2) the requirements of section 804(a)(1) shall be deemed 
     met.

     The Secretary may by regulation define for purposes of this 
     subsection the terms `franchiser', `franchise network', and 
     `franchisee'.

     ``SEC. 804. PARTICIPATION AND COVERAGE REQUIREMENTS.

       ``(a) Covered Employers and Individuals.--The requirements 
     of this subsection are met with respect to an association 
     health plan if, under the terms of the plan--
       ``(1) each participating employer must be--
       ``(A) a member of the sponsor,
       ``(B) the sponsor, or

[[Page 27540]]

       ``(C) an affiliated member of the sponsor with respect to 
     which the requirements of subsection (b) are met,

     except that, in the case of a sponsor which is a professional 
     association or other individual-based association, if at 
     least one of the officers, directors, or employees of an 
     employer, or at least one of the individuals who are partners 
     in an employer and who actively participates in the business, 
     is a member or such an affiliated member of the sponsor, 
     participating employers may also include such employer; and
       ``(2) all individuals commencing coverage under the plan 
     after certification under this part must be--
       ``(A) active or retired owners (including self-employed 
     individuals), officers, directors, or employees of, or 
     partners in, participating employers; or
       ``(B) the beneficiaries of individuals described in 
     subparagraph (A).
       ``(b) Coverage of Previously Uninsured Employees.--In the 
     case of an association health plan in existence on the date 
     of the enactment of the Small Business Health Fairness Act of 
     2009, an affiliated member of the sponsor of the plan may be 
     offered coverage under the plan as a participating employer 
     only if--
       ``(1) the affiliated member was an affiliated member on the 
     date of certification under this part; or
       ``(2) during the 12-month period preceding the date of the 
     offering of such coverage, the affiliated member has not 
     maintained or contributed to a group health plan with respect 
     to any of its employees who would otherwise be eligible to 
     participate in such association health plan.
       ``(c) Individual Market Unaffected.--The requirements of 
     this subsection are met with respect to an association health 
     plan if, under the terms of the plan, no participating 
     employer may provide health insurance coverage in the 
     individual market for any employee not covered under the plan 
     which is similar to the coverage contemporaneously provided 
     to employees of the employer under the plan, if such 
     exclusion of the employee from coverage under the plan is 
     based on a health status-related factor with respect to the 
     employee and such employee would, but for such exclusion on 
     such basis, be eligible for coverage under the plan.
       ``(d) Prohibition of Discrimination Against Employers and 
     Employees Eligible To Participate.--The requirements of this 
     subsection are met with respect to an association health plan 
     if--
       ``(1) under the terms of the plan, all employers meeting 
     the preceding requirements of this section are eligible to 
     qualify as participating employers for all geographically 
     available coverage options, unless, in the case of any such 
     employer, participation or contribution requirements of the 
     type referred to in section 2711 of the Public Health Service 
     Act are not met;
       ``(2) upon request, any employer eligible to participate is 
     furnished information regarding all coverage options 
     available under the plan; and
       ``(3) the applicable requirements of sections 701, 702, and 
     703 are met with respect to the plan.

     ``SEC. 805. OTHER REQUIREMENTS RELATING TO PLAN DOCUMENTS, 
                   CONTRIBUTION RATES, AND BENEFIT OPTIONS.

       ``(a) In General.--The requirements of this section are met 
     with respect to an association health plan if the following 
     requirements are met:
       ``(1) Contents of governing instruments.--The instruments 
     governing the plan include a written instrument, meeting the 
     requirements of an instrument required under section 
     402(a)(1), which--
       ``(A) provides that the board of trustees serves as the 
     named fiduciary required for plans under section 402(a)(1) 
     and serves in the capacity of a plan administrator (referred 
     to in section 3(16)(A));
       ``(B) provides that the sponsor of the plan is to serve as 
     plan sponsor (referred to in section 3(16)(B)); and
       ``(C) incorporates the requirements of section 806.
       ``(2) Contribution rates must be nondiscriminatory.--
       ``(A) The contribution rates for any participating small 
     employer do not vary on the basis of any health status-
     related factor in relation to employees of such employer or 
     their beneficiaries and do not vary on the basis of the type 
     of business or industry in which such employer is engaged.
       ``(B) Nothing in this title or any other provision of law 
     shall be construed to preclude an association health plan, or 
     a health insurance issuer offering health insurance coverage 
     in connection with an association health plan, from--
       ``(i) setting contribution rates based on the claims 
     experience of the plan; or
       ``(ii) varying contribution rates for small employers in a 
     State to the extent that such rates could vary using the same 
     methodology employed in such State for regulating premium 
     rates in the small group market with respect to health 
     insurance coverage offered in connection with bona fide 
     associations (within the meaning of section 2791(d)(3) of the 
     Public Health Service Act),

     subject to the requirements of section 702(b) relating to 
     contribution rates.
       ``(3) Floor for number of covered individuals with respect 
     to certain plans.--If any benefit option under the plan does 
     not consist of health insurance coverage, the plan has as of 
     the beginning of the plan year not fewer than 1,000 
     participants and beneficiaries.
       ``(4) Marketing requirements.--
       ``(A) In general.--If a benefit option which consists of 
     health insurance coverage is offered under the plan, State-
     licensed insurance agents shall be used to distribute to 
     small employers coverage which does not consist of health 
     insurance coverage in a manner comparable to the manner in 
     which such agents are used to distribute health insurance 
     coverage.
       ``(B) State-licensed insurance agents.--For purposes of 
     subparagraph (A), the term `State-licensed insurance agents' 
     means one or more agents who are licensed in a State and are 
     subject to the laws of such State relating to licensure, 
     qualification, testing, examination, and continuing education 
     of persons authorized to offer, sell, or solicit health 
     insurance coverage in such State.
       ``(5) Regulatory requirements.--Such other requirements as 
     the applicable authority determines are necessary to carry 
     out the purposes of this part, which shall be prescribed by 
     the applicable authority by regulation.
       ``(b) Ability of Association Health Plans To Design Benefit 
     Options.--Subject to section 514(d), nothing in this part or 
     any provision of State law (as defined in section 514(c)(1)) 
     shall be construed to preclude an association health plan, or 
     a health insurance issuer offering health insurance coverage 
     in connection with an association health plan, from 
     exercising its sole discretion in selecting the specific 
     items and services consisting of medical care to be included 
     as benefits under such plan or coverage, except (subject to 
     section 514) in the case of (1) any law to the extent that it 
     is not preempted under section 731(a)(1) with respect to 
     matters governed by section 711, 712, or 713, or (2) any law 
     of the State with which filing and approval of a policy type 
     offered by the plan was initially obtained to the extent that 
     such law prohibits an exclusion of a specific disease from 
     such coverage.

     ``SEC. 806. MAINTENANCE OF RESERVES AND PROVISIONS FOR 
                   SOLVENCY FOR PLANS PROVIDING HEALTH BENEFITS IN 
                   ADDITION TO HEALTH INSURANCE COVERAGE.

       ``(a) In General.--The requirements of this section are met 
     with respect to an association health plan if--
       ``(1) the benefits under the plan consist solely of health 
     insurance coverage; or
       ``(2) if the plan provides any additional benefit options 
     which do not consist of health insurance coverage, the plan--
       ``(A) establishes and maintains reserves with respect to 
     such additional benefit options, in amounts recommended by 
     the qualified actuary, consisting of--
       ``(i) a reserve sufficient for unearned contributions;
       ``(ii) a reserve sufficient for benefit liabilities which 
     have been incurred, which have not been satisfied, and for 
     which risk of loss has not yet been transferred, and for 
     expected administrative costs with respect to such benefit 
     liabilities;
       ``(iii) a reserve sufficient for any other obligations of 
     the plan; and
       ``(iv) a reserve sufficient for a margin of error and other 
     fluctuations, taking into account the specific circumstances 
     of the plan; and
       ``(B) establishes and maintains aggregate and specific 
     excess/stop loss insurance and solvency indemnification, with 
     respect to such additional benefit options for which risk of 
     loss has not yet been transferred, as follows:
       ``(i) The plan shall secure aggregate excess/stop loss 
     insurance for the plan with an attachment point which is not 
     greater than 125 percent of expected gross annual claims. The 
     applicable authority may by regulation provide for upward 
     adjustments in the amount of such percentage in specified 
     circumstances in which the plan specifically provides for and 
     maintains reserves in excess of the amounts required under 
     subparagraph (A).
       ``(ii) The plan shall secure specific excess/stop loss 
     insurance for the plan with an attachment point which is at 
     least equal to an amount recommended by the plan's qualified 
     actuary. The applicable authority may by regulation provide 
     for adjustments in the amount of such insurance in specified 
     circumstances in which the plan specifically provides for and 
     maintains reserves in excess of the amounts required under 
     subparagraph (A).
       ``(iii) The plan shall secure indemnification insurance for 
     any claims which the plan is unable to satisfy by reason of a 
     plan termination.

     Any person issuing to a plan insurance described in clause 
     (i), (ii), or (iii) of subparagraph (B) shall notify the 
     Secretary of any failure of premium payment meriting 
     cancellation of the policy prior to undertaking such a 
     cancellation. Any regulations prescribed by the applicable 
     authority pursuant to clause (i) or (ii) of subparagraph (B) 
     may allow for such adjustments in the required levels of 
     excess/stop loss insurance as the qualified actuary may 
     recommend, taking

[[Page 27541]]

     into account the specific circumstances of the plan.
       ``(b) Minimum Surplus in Addition to Claims Reserves.--In 
     the case of any association health plan described in 
     subsection (a)(2), the requirements of this subsection are 
     met if the plan establishes and maintains surplus in an 
     amount at least equal to--
       ``(1) $500,000, or
       ``(2) such greater amount (but not greater than $2,000,000) 
     as may be set forth in regulations prescribed by the 
     applicable authority, considering the level of aggregate and 
     specific excess/stop loss insurance provided with respect to 
     such plan and other factors related to solvency risk, such as 
     the plan's projected levels of participation or claims, the 
     nature of the plan's liabilities, and the types of assets 
     available to assure that such liabilities are met.
       ``(c) Additional Requirements.--In the case of any 
     association health plan described in subsection (a)(2), the 
     applicable authority may provide such additional requirements 
     relating to reserves, excess/stop loss insurance, and 
     indemnification insurance as the applicable authority 
     considers appropriate. Such requirements may be provided by 
     regulation with respect to any such plan or any class of such 
     plans.
       ``(d) Adjustments for Excess/Stop Loss Insurance.--The 
     applicable authority may provide for adjustments to the 
     levels of reserves otherwise required under subsections (a) 
     and (b) with respect to any plan or class of plans to take 
     into account excess/stop loss insurance provided with respect 
     to such plan or plans.
       ``(e) Alternative Means of Compliance.--The applicable 
     authority may permit an association health plan described in 
     subsection (a)(2) to substitute, for all or part of the 
     requirements of this section (except subsection 
     (a)(2)(B)(iii)), such security, guarantee, hold-harmless 
     arrangement, or other financial arrangement as the applicable 
     authority determines to be adequate to enable the plan to 
     fully meet all its financial obligations on a timely basis 
     and is otherwise no less protective of the interests of 
     participants and beneficiaries than the requirements for 
     which it is substituted. The applicable authority may take 
     into account, for purposes of this subsection, evidence 
     provided by the plan or sponsor which demonstrates an 
     assumption of liability with respect to the plan. Such 
     evidence may be in the form of a contract of indemnification, 
     lien, bonding, insurance, letter of credit, recourse under 
     applicable terms of the plan in the form of assessments of 
     participating employers, security, or other financial 
     arrangement.
       ``(f) Measures To Ensure Continued Payment of Benefits by 
     Certain Plans in Distress.--
       ``(1) Payments by certain plans to association health plan 
     fund.--
       ``(A) In general.--In the case of an association health 
     plan described in subsection (a)(2), the requirements of this 
     subsection are met if the plan makes payments into the 
     Association Health Plan Fund under this subparagraph when 
     they are due. Such payments shall consist of annual payments 
     in the amount of $5,000, and, in addition to such annual 
     payments, such supplemental payments as the Secretary may 
     determine to be necessary under paragraph (2). Payments under 
     this paragraph are payable to the Fund at the time determined 
     by the Secretary. Initial payments are due in advance of 
     certification under this part. Payments shall continue to 
     accrue until a plan's assets are distributed pursuant to a 
     termination procedure.
       ``(B) Penalties for failure to make payments.--If any 
     payment is not made by a plan when it is due, a late payment 
     charge of not more than 100 percent of the payment which was 
     not timely paid shall be payable by the plan to the Fund.
       ``(C) Continued duty of the secretary.--The Secretary shall 
     not cease to carry out the provisions of paragraph (2) on 
     account of the failure of a plan to pay any payment when due.
       ``(2) Payments by secretary to continue excess/stop loss 
     insurance coverage and indemnification insurance coverage for 
     certain plans.--In any case in which the applicable authority 
     determines that there is, or that there is reason to believe 
     that there will be: (A) a failure to take necessary 
     corrective actions under section 809(a) with respect to an 
     association health plan described in subsection (a)(2); or 
     (B) a termination of such a plan under section 809(b) or 
     810(b)(8) (and, if the applicable authority is not the 
     Secretary, certifies such determination to the Secretary), 
     the Secretary shall determine the amounts necessary to make 
     payments to an insurer (designated by the Secretary) to 
     maintain in force excess/stop loss insurance coverage or 
     indemnification insurance coverage for such plan, if the 
     Secretary determines that there is a reasonable expectation 
     that, without such payments, claims would not be satisfied by 
     reason of termination of such coverage. The Secretary shall, 
     to the extent provided in advance in appropriation Acts, pay 
     such amounts so determined to the insurer designated by the 
     Secretary.
       ``(3) Association health plan fund.--
       ``(A) In general.--There is established on the books of the 
     Treasury a fund to be known as the `Association Health Plan 
     Fund'. The Fund shall be available for making payments 
     pursuant to paragraph (2). The Fund shall be credited with 
     payments received pursuant to paragraph (1)(A), penalties 
     received pursuant to paragraph (1)(B); and earnings on 
     investments of amounts of the Fund under subparagraph (B).
       ``(B) Investment.--Whenever the Secretary determines that 
     the moneys of the fund are in excess of current needs, the 
     Secretary may request the investment of such amounts as the 
     Secretary determines advisable by the Secretary of the 
     Treasury in obligations issued or guaranteed by the United 
     States.
       ``(g) Excess/Stop Loss Insurance.--For purposes of this 
     section--
       ``(1) Aggregate excess/stop loss insurance.--The term 
     `aggregate excess/stop loss insurance' means, in connection 
     with an association health plan, a contract--
       ``(A) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe by 
     regulation) provides for payment to the plan with respect to 
     aggregate claims under the plan in excess of an amount or 
     amounts specified in such contract;
       ``(B) which is guaranteed renewable; and
       ``(C) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(2) Specific excess/stop loss insurance.--The term 
     `specific excess/stop loss insurance' means, in connection 
     with an association health plan, a contract--
       ``(A) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe by 
     regulation) provides for payment to the plan with respect to 
     claims under the plan in connection with a covered individual 
     in excess of an amount or amounts specified in such contract 
     in connection with such covered individual;
       ``(B) which is guaranteed renewable; and
       ``(C) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(h) Indemnification Insurance.--For purposes of this 
     section, the term `indemnification insurance' means, in 
     connection with an association health plan, a contract--
       ``(1) under which an insurer (meeting such minimum 
     standards as the applicable authority may prescribe by 
     regulation) provides for payment to the plan with respect to 
     claims under the plan which the plan is unable to satisfy by 
     reason of a termination pursuant to section 809(b) (relating 
     to mandatory termination);
       ``(2) which is guaranteed renewable and noncancellable for 
     any reason (except as the applicable authority may prescribe 
     by regulation); and
       ``(3) which allows for payment of premiums by any third 
     party on behalf of the insured plan.
       ``(i) Reserves.--For purposes of this section, the term 
     `reserves' means, in connection with an association health 
     plan, plan assets which meet the fiduciary standards under 
     part 4 and such additional requirements regarding liquidity 
     as the applicable authority may prescribe by regulation.
       ``(j) Solvency Standards Working Group.--
       ``(1) In general.--Within 90 days after the date of the 
     enactment of the Small Business Health Fairness Act of 2009, 
     the applicable authority shall establish a Solvency Standards 
     Working Group. In prescribing the initial regulations under 
     this section, the applicable authority shall take into 
     account the recommendations of such Working Group.
       ``(2) Membership.--The Working Group shall consist of not 
     more than 15 members appointed by the applicable authority. 
     The applicable authority shall include among persons invited 
     to membership on the Working Group at least one of each of 
     the following:
       ``(A) a representative of the National Association of 
     Insurance Commissioners;
       ``(B) a representative of the American Academy of 
     Actuaries;
       ``(C) a representative of the State governments, or their 
     interests;
       ``(D) a representative of existing self-insured 
     arrangements, or their interests;
       ``(E) a representative of associations of the type referred 
     to in section 801(b)(1), or their interests; and
       ``(F) a representative of multiemployer plans that are 
     group health plans, or their interests.

     ``SEC. 807. REQUIREMENTS FOR APPLICATION AND RELATED 
                   REQUIREMENTS.

       ``(a) Filing Fee.--Under the procedure prescribed pursuant 
     to section 802(a), an association health plan shall pay to 
     the applicable authority at the time of filing an application 
     for certification under this part a filing fee in the amount 
     of $5,000, which shall be available in the case of the 
     Secretary, to the extent provided in appropriation Acts, for 
     the sole purpose of administering the certification 
     procedures applicable with respect to association health 
     plans.
       ``(b) Information To Be Included in Application for 
     Certification.--An application for certification under this 
     part meets the requirements of this section only if it 
     includes, in a manner and form which shall be prescribed by 
     the applicable authority by regulation, at least the 
     following information:
       ``(1) Identifying information.--The names and addresses 
     of--

[[Page 27542]]

       ``(A) the sponsor; and
       ``(B) the members of the board of trustees of the plan.
       ``(2) States in which plan intends to do business.--The 
     States in which participants and beneficiaries under the plan 
     are to be located and the number of them expected to be 
     located in each such State.
       ``(3) Bonding requirements.--Evidence provided by the board 
     of trustees that the bonding requirements of section 412 will 
     be met as of the date of the application or (if later) 
     commencement of operations.
       ``(4) Plan documents.--A copy of the documents governing 
     the plan (including any bylaws and trust agreements), the 
     summary plan description, and other material describing the 
     benefits that will be provided to participants and 
     beneficiaries under the plan.
       ``(5) Agreements with service providers.--A copy of any 
     agreements between the plan and contract administrators and 
     other service providers.
       ``(6) Funding report.--In the case of association health 
     plans providing benefits options in addition to health 
     insurance coverage, a report setting forth information with 
     respect to such additional benefit options determined as of a 
     date within the 120-day period ending with the date of the 
     application, including the following:
       ``(A) Reserves.--A statement, certified by the board of 
     trustees of the plan, and a statement of actuarial opinion, 
     signed by a qualified actuary, that all applicable 
     requirements of section 806 are or will be met in accordance 
     with regulations which the applicable authority shall 
     prescribe.
       ``(B) Adequacy of contribution rates.--A statement of 
     actuarial opinion, signed by a qualified actuary, which sets 
     forth a description of the extent to which contribution rates 
     are adequate to provide for the payment of all obligations 
     and the maintenance of required reserves under the plan for 
     the 12-month period beginning with such date within such 120-
     day period, taking into account the expected coverage and 
     experience of the plan. If the contribution rates are not 
     fully adequate, the statement of actuarial opinion shall 
     indicate the extent to which the rates are inadequate and the 
     changes needed to ensure adequacy.
       ``(C) Current and projected value of assets and 
     liabilities.--A statement of actuarial opinion signed by a 
     qualified actuary, which sets forth the current value of the 
     assets and liabilities accumulated under the plan and a 
     projection of the assets, liabilities, income, and expenses 
     of the plan for the 12-month period referred to in 
     subparagraph (B). The income statement shall identify 
     separately the plan's administrative expenses and claims.
       ``(D) Costs of coverage to be charged and other expenses.--
     A statement of the costs of coverage to be charged, including 
     an itemization of amounts for administration, reserves, and 
     other expenses associated with the operation of the plan.
       ``(E) Other information.--Any other information as may be 
     determined by the applicable authority, by regulation, as 
     necessary to carry out the purposes of this part.
       ``(c) Filing Notice of Certification With States.--A 
     certification granted under this part to an association 
     health plan shall not be effective unless written notice of 
     such certification is filed with the applicable State 
     authority of each State in which at least 25 percent of the 
     participants and beneficiaries under the plan are located. 
     For purposes of this subsection, an individual shall be 
     considered to be located in the State in which a known 
     address of such individual is located or in which such 
     individual is employed.
       ``(d) Notice of Material Changes.--In the case of any 
     association health plan certified under this part, 
     descriptions of material changes in any information which was 
     required to be submitted with the application for the 
     certification under this part shall be filed in such form and 
     manner as shall be prescribed by the applicable authority by 
     regulation. The applicable authority may require by 
     regulation prior notice of material changes with respect to 
     specified matters which might serve as the basis for 
     suspension or revocation of the certification.
       ``(e) Reporting Requirements for Certain Association Health 
     Plans.--An association health plan certified under this part 
     which provides benefit options in addition to health 
     insurance coverage for such plan year shall meet the 
     requirements of section 103 by filing an annual report under 
     such section which shall include information described in 
     subsection (b)(6) with respect to the plan year and, 
     notwithstanding section 104(a)(1)(A), shall be filed with the 
     applicable authority not later than 90 days after the close 
     of the plan year (or on such later date as may be prescribed 
     by the applicable authority). The applicable authority may 
     require by regulation such interim reports as it considers 
     appropriate.
       ``(f) Engagement of Qualified Actuary.--The board of 
     trustees of each association health plan which provides 
     benefits options in addition to health insurance coverage and 
     which is applying for certification under this part or is 
     certified under this part shall engage, on behalf of all 
     participants and beneficiaries, a qualified actuary who shall 
     be responsible for the preparation of the materials 
     comprising information necessary to be submitted by a 
     qualified actuary under this part. The qualified actuary 
     shall utilize such assumptions and techniques as are 
     necessary to enable such actuary to form an opinion as to 
     whether the contents of the matters reported under this 
     part--
       ``(1) are in the aggregate reasonably related to the 
     experience of the plan and to reasonable expectations; and
       ``(2) represent such actuary's best estimate of anticipated 
     experience under the plan.

     The opinion by the qualified actuary shall be made with 
     respect to, and shall be made a part of, the annual report.

     ``SEC. 808. NOTICE REQUIREMENTS FOR VOLUNTARY TERMINATION.

       ``Except as provided in section 809(b), an association 
     health plan which is or has been certified under this part 
     may terminate (upon or at any time after cessation of 
     accruals in benefit liabilities) only if the board of 
     trustees, not less than 60 days before the proposed 
     termination date--
       ``(1) provides to the participants and beneficiaries a 
     written notice of intent to terminate stating that such 
     termination is intended and the proposed termination date;
       ``(2) develops a plan for winding up the affairs of the 
     plan in connection with such termination in a manner which 
     will result in timely payment of all benefits for which the 
     plan is obligated; and
       ``(3) submits such plan in writing to the applicable 
     authority.

     Actions required under this section shall be taken in such 
     form and manner as may be prescribed by the applicable 
     authority by regulation.

     ``SEC. 809. CORRECTIVE ACTIONS AND MANDATORY TERMINATION.

       ``(a) Actions To Avoid Depletion of Reserves.--An 
     association health plan which is certified under this part 
     and which provides benefits other than health insurance 
     coverage shall continue to meet the requirements of section 
     806, irrespective of whether such certification continues in 
     effect. The board of trustees of such plan shall determine 
     quarterly whether the requirements of section 806 are met. In 
     any case in which the board determines that there is reason 
     to believe that there is or will be a failure to meet such 
     requirements, or the applicable authority makes such a 
     determination and so notifies the board, the board shall 
     immediately notify the qualified actuary engaged by the plan, 
     and such actuary shall, not later than the end of the next 
     following month, make such recommendations to the board for 
     corrective action as the actuary determines necessary to 
     ensure compliance with section 806. Not later than 30 days 
     after receiving from the actuary recommendations for 
     corrective actions, the board shall notify the applicable 
     authority (in such form and manner as the applicable 
     authority may prescribe by regulation) of such 
     recommendations of the actuary for corrective action, 
     together with a description of the actions (if any) that the 
     board has taken or plans to take in response to such 
     recommendations. The board shall thereafter report to the 
     applicable authority, in such form and frequency as the 
     applicable authority may specify to the board, regarding 
     corrective action taken by the board until the requirements 
     of section 806 are met.
       ``(b) Mandatory Termination.--In any case in which--
       ``(1) the applicable authority has been notified under 
     subsection (a) (or by an issuer of excess/stop loss insurance 
     or indemnity insurance pursuant to section 806(a)) of a 
     failure of an association health plan which is or has been 
     certified under this part and is described in section 
     806(a)(2) to meet the requirements of section 806 and has not 
     been notified by the board of trustees of the plan that 
     corrective action has restored compliance with such 
     requirements; and
       ``(2) the applicable authority determines that there is a 
     reasonable expectation that the plan will continue to fail to 
     meet the requirements of section 806,

     the board of trustees of the plan shall, at the direction of 
     the applicable authority, terminate the plan and, in the 
     course of the termination, take such actions as the 
     applicable authority may require, including satisfying any 
     claims referred to in section 806(a)(2)(B)(iii) and 
     recovering for the plan any liability under subsection 
     (a)(2)(B)(iii) or (e) of section 806, as necessary to ensure 
     that the affairs of the plan will be, to the maximum extent 
     possible, wound up in a manner which will result in timely 
     provision of all benefits for which the plan is obligated.

     ``SEC. 810. TRUSTEESHIP BY THE SECRETARY OF INSOLVENT 
                   ASSOCIATION HEALTH PLANS PROVIDING HEALTH 
                   BENEFITS IN ADDITION TO HEALTH INSURANCE 
                   COVERAGE.

       ``(a) Appointment of Secretary as Trustee for Insolvent 
     Plans.--Whenever the Secretary determines that an association 
     health plan which is or has been certified under this part 
     and which is described in section 806(a)(2) will be unable to 
     provide benefits when due or is otherwise in a financially 
     hazardous condition, as shall be defined by the Secretary by 
     regulation, the Secretary shall, upon notice to the plan, 
     apply to the appropriate United States district court for 
     appointment of the Secretary as trustee to administer the 
     plan for the duration of the insolvency. The plan may appear 
     as a party

[[Page 27543]]

     and other interested persons may intervene in the proceedings 
     at the discretion of the court. The court shall appoint such 
     Secretary trustee if the court determines that the 
     trusteeship is necessary to protect the interests of the 
     participants and beneficiaries or providers of medical care 
     or to avoid any unreasonable deterioration of the financial 
     condition of the plan. The trusteeship of such Secretary 
     shall continue until the conditions described in the first 
     sentence of this subsection are remedied or the plan is 
     terminated.
       ``(b) Powers as Trustee.--The Secretary, upon appointment 
     as trustee under subsection (a), shall have the power--
       ``(1) to do any act authorized by the plan, this title, or 
     other applicable provisions of law to be done by the plan 
     administrator or any trustee of the plan;
       ``(2) to require the transfer of all (or any part) of the 
     assets and records of the plan to the Secretary as trustee;
       ``(3) to invest any assets of the plan which the Secretary 
     holds in accordance with the provisions of the plan, 
     regulations prescribed by the Secretary, and applicable 
     provisions of law;
       ``(4) to require the sponsor, the plan administrator, any 
     participating employer, and any employee organization 
     representing plan participants to furnish any information 
     with respect to the plan which the Secretary as trustee may 
     reasonably need in order to administer the plan;
       ``(5) to collect for the plan any amounts due the plan and 
     to recover reasonable expenses of the trusteeship;
       ``(6) to commence, prosecute, or defend on behalf of the 
     plan any suit or proceeding involving the plan;
       ``(7) to issue, publish, or file such notices, statements, 
     and reports as may be required by the Secretary by regulation 
     or required by any order of the court;
       ``(8) to terminate the plan (or provide for its termination 
     in accordance with section 809(b)) and liquidate the plan 
     assets, to restore the plan to the responsibility of the 
     sponsor, or to continue the trusteeship;
       ``(9) to provide for the enrollment of plan participants 
     and beneficiaries under appropriate coverage options; and
       ``(10) to do such other acts as may be necessary to comply 
     with this title or any order of the court and to protect the 
     interests of plan participants and beneficiaries and 
     providers of medical care.
       ``(c) Notice of Appointment.--As soon as practicable after 
     the Secretary's appointment as trustee, the Secretary shall 
     give notice of such appointment to--
       ``(1) the sponsor and plan administrator;
       ``(2) each participant;
       ``(3) each participating employer; and
       ``(4) if applicable, each employee organization which, for 
     purposes of collective bargaining, represents plan 
     participants.
       ``(d) Additional Duties.--Except to the extent inconsistent 
     with the provisions of this title, or as may be otherwise 
     ordered by the court, the Secretary, upon appointment as 
     trustee under this section, shall be subject to the same 
     duties as those of a trustee under section 704 of title 11, 
     United States Code, and shall have the duties of a fiduciary 
     for purposes of this title.
       ``(e) Other Proceedings.--An application by the Secretary 
     under this subsection may be filed notwithstanding the 
     pendency in the same or any other court of any bankruptcy, 
     mortgage foreclosure, or equity receivership proceeding, or 
     any proceeding to reorganize, conserve, or liquidate such 
     plan or its property, or any proceeding to enforce a lien 
     against property of the plan.
       ``(f) Jurisdiction of Court.--
       ``(1) In general.--Upon the filing of an application for 
     the appointment as trustee or the issuance of a decree under 
     this section, the court to which the application is made 
     shall have exclusive jurisdiction of the plan involved and 
     its property wherever located with the powers, to the extent 
     consistent with the purposes of this section, of a court of 
     the United States having jurisdiction over cases under 
     chapter 11 of title 11, United States Code. Pending an 
     adjudication under this section such court shall stay, and 
     upon appointment by it of the Secretary as trustee, such 
     court shall continue the stay of, any pending mortgage 
     foreclosure, equity receivership, or other proceeding to 
     reorganize, conserve, or liquidate the plan, the sponsor, or 
     property of such plan or sponsor, and any other suit against 
     any receiver, conservator, or trustee of the plan, the 
     sponsor, or property of the plan or sponsor. Pending such 
     adjudication and upon the appointment by it of the Secretary 
     as trustee, the court may stay any proceeding to enforce a 
     lien against property of the plan or the sponsor or any other 
     suit against the plan or the sponsor.
       ``(2) Venue.--An action under this section may be brought 
     in the judicial district where the sponsor or the plan 
     administrator resides or does business or where any asset of 
     the plan is situated. A district court in which such action 
     is brought may issue process with respect to such action in 
     any other judicial district.
       ``(g) Personnel.--In accordance with regulations which 
     shall be prescribed by the Secretary, the Secretary shall 
     appoint, retain, and compensate accountants, actuaries, and 
     other professional service personnel as may be necessary in 
     connection with the Secretary's service as trustee under this 
     section.

     ``SEC. 811. STATE ASSESSMENT AUTHORITY.

       ``(a) In General.--Notwithstanding section 514, a State may 
     impose by law a contribution tax on an association health 
     plan described in section 806(a)(2), if the plan commenced 
     operations in such State after the date of the enactment of 
     the Small Business Health Fairness Act of 2009.
       ``(b) Contribution Tax.--For purposes of this section, the 
     term `contribution tax' imposed by a State on an association 
     health plan means any tax imposed by such State if--
       ``(1) such tax is computed by applying a rate to the amount 
     of premiums or contributions, with respect to individuals 
     covered under the plan who are residents of such State, which 
     are received by the plan from participating employers located 
     in such State or from such individuals;
       ``(2) the rate of such tax does not exceed the rate of any 
     tax imposed by such State on premiums or contributions 
     received by insurers or health maintenance organizations for 
     health insurance coverage offered in such State in connection 
     with a group health plan;
       ``(3) such tax is otherwise nondiscriminatory; and
       ``(4) the amount of any such tax assessed on the plan is 
     reduced by the amount of any tax or assessment otherwise 
     imposed by the State on premiums, contributions, or both 
     received by insurers or health maintenance organizations for 
     health insurance coverage, aggregate excess/stop loss 
     insurance (as defined in section 806(g)(1)), specific excess/
     stop loss insurance (as defined in section 806(g)(2)), other 
     insurance related to the provision of medical care under the 
     plan, or any combination thereof provided by such insurers or 
     health maintenance organizations in such State in connection 
     with such plan.

     ``SEC. 812. DEFINITIONS AND RULES OF CONSTRUCTION.

       ``(a) Definitions.--For purposes of this part--
       ``(1) Group health plan.--The term `group health plan' has 
     the meaning provided in section 733(a)(1) (after applying 
     subsection (b) of this section).
       ``(2) Medical care.--The term `medical care' has the 
     meaning provided in section 733(a)(2).
       ``(3) Health insurance coverage.--The term `health 
     insurance coverage' has the meaning provided in section 
     733(b)(1).
       ``(4) Health insurance issuer.--The term `health insurance 
     issuer' has the meaning provided in section 733(b)(2).
       ``(5) Applicable authority.--The term `applicable 
     authority' means the Secretary, except that, in connection 
     with any exercise of the Secretary's authority regarding 
     which the Secretary is required under section 506(d) to 
     consult with a State, such term means the Secretary, in 
     consultation with such State.
       ``(6) Health status-related factor.--The term `health 
     status-related factor' has the meaning provided in section 
     733(d)(2).
       ``(7) Individual market.--
       ``(A) In general.--The term `individual market' means the 
     market for health insurance coverage offered to individuals 
     other than in connection with a group health plan.
       ``(B) Treatment of very small groups.--
       ``(i) In general.--Subject to clause (ii), such term 
     includes coverage offered in connection with a group health 
     plan that has fewer than 2 participants as current employees 
     or participants described in section 732(d)(3) on the first 
     day of the plan year.
       ``(ii) State exception.--Clause (i) shall not apply in the 
     case of health insurance coverage offered in a State if such 
     State regulates the coverage described in such clause in the 
     same manner and to the same extent as coverage in the small 
     group market (as defined in section 2791(e)(5) of the Public 
     Health Service Act) is regulated by such State.
       ``(8) Participating employer.--The term `participating 
     employer' means, in connection with an association health 
     plan, any employer, if any individual who is an employee of 
     such employer, a partner in such employer, or a self-employed 
     individual who is such employer (or any dependent, as defined 
     under the terms of the plan, of such individual) is or was 
     covered under such plan in connection with the status of such 
     individual as such an employee, partner, or self-employed 
     individual in relation to the plan.
       ``(9) Applicable state authority.--The term `applicable 
     State authority' means, with respect to a health insurance 
     issuer in a State, the State insurance commissioner or 
     official or officials designated by the State to enforce the 
     requirements of title XXVII of the Public Health Service Act 
     for the State involved with respect to such issuer.
       ``(10) Qualified actuary.--The term `qualified actuary' 
     means an individual who is a member of the American Academy 
     of Actuaries.
       ``(11) Affiliated member.--The term `affiliated member' 
     means, in connection with a sponsor--
       ``(A) a person who is otherwise eligible to be a member of 
     the sponsor but who elects an affiliated status with the 
     sponsor,
       ``(B) in the case of a sponsor with members which consist 
     of associations, a person who

[[Page 27544]]

     is a member of any such association and elects an affiliated 
     status with the sponsor, or
       ``(C) in the case of an association health plan in 
     existence on the date of the enactment of the Small Business 
     Health Fairness Act of 2009, a person eligible to be a member 
     of the sponsor or one of its member associations.
       ``(12) Large employer.--The term `large employer' means, in 
     connection with a group health plan with respect to a plan 
     year, an employer who employed an average of at least 51 
     employees on business days during the preceding calendar year 
     and who employs at least 2 employees on the first day of the 
     plan year.
       ``(13) Small employer.--The term `small employer' means, in 
     connection with a group health plan with respect to a plan 
     year, an employer who is not a large employer.
       ``(b) Rules of Construction.--
       ``(1) Employers and employees.--For purposes of determining 
     whether a plan, fund, or program is an employee welfare 
     benefit plan which is an association health plan, and for 
     purposes of applying this title in connection with such plan, 
     fund, or program so determined to be such an employee welfare 
     benefit plan--
       ``(A) in the case of a partnership, the term `employer' (as 
     defined in section 3(5)) includes the partnership in relation 
     to the partners, and the term `employee' (as defined in 
     section 3(6)) includes any partner in relation to the 
     partnership; and
       ``(B) in the case of a self-employed individual, the term 
     `employer' (as defined in section 3(5)) and the term 
     `employee' (as defined in section 3(6)) shall include such 
     individual.
       ``(2) Plans, funds, and programs treated as employee 
     welfare benefit plans.--In the case of any plan, fund, or 
     program which was established or is maintained for the 
     purpose of providing medical care (through the purchase of 
     insurance or otherwise) for employees (or their dependents) 
     covered thereunder and which demonstrates to the Secretary 
     that all requirements for certification under this part would 
     be met with respect to such plan, fund, or program if such 
     plan, fund, or program were a group health plan, such plan, 
     fund, or program shall be treated for purposes of this title 
     as an employee welfare benefit plan on and after the date of 
     such demonstration.''.
       (b) Conforming Amendments to Preemption Rules.--
       (1) Section 514(b)(6) of such Act (29 U.S.C. 1144(b)(6)) is 
     amended by adding at the end the following new subparagraph:
       ``(E) The preceding subparagraphs of this paragraph do not 
     apply with respect to any State law in the case of an 
     association health plan which is certified under part 8.''.
       (2) Section 514 of such Act (29 U.S.C. 1144) is amended--
       (A) in subsection (b)(4), by striking ``Subsection (a)'' 
     and inserting ``Subsections (a) and (d)'';
       (B) in subsection (b)(5), by striking ``subsection (a)'' in 
     subparagraph (A) and inserting ``subsection (a) of this 
     section and subsections (a)(2)(B) and (b) of section 805'', 
     and by striking ``subsection (a)'' in subparagraph (B) and 
     inserting ``subsection (a) of this section or subsection 
     (a)(2)(B) or (b) of section 805'';
       (C) by redesignating subsections (d) and (e) as subsections 
     (e) and (f), respectively; and
       (D) by inserting after subsection (c) the following new 
     subsection:
       ``(d)(1) Except as provided in subsection (b)(4), the 
     provisions of this title shall supersede any and all State 
     laws insofar as they may now or hereafter preclude, or have 
     the effect of precluding, a health insurance issuer from 
     offering health insurance coverage in connection with an 
     association health plan which is certified under part 8.
       ``(2) Except as provided in paragraphs (4) and (5) of 
     subsection (b) of this section--
       ``(A) In any case in which health insurance coverage of any 
     policy type is offered under an association health plan 
     certified under part 8 to a participating employer operating 
     in such State, the provisions of this title shall supersede 
     any and all laws of such State insofar as they may preclude a 
     health insurance issuer from offering health insurance 
     coverage of the same policy type to other employers operating 
     in the State which are eligible for coverage under such 
     association health plan, whether or not such other employers 
     are participating employers in such plan.
       ``(B) In any case in which health insurance coverage of any 
     policy type is offered in a State under an association health 
     plan certified under part 8 and the filing, with the 
     applicable State authority (as defined in section 812(a)(9)), 
     of the policy form in connection with such policy type is 
     approved by such State authority, the provisions of this 
     title shall supersede any and all laws of any other State in 
     which health insurance coverage of such type is offered, 
     insofar as they may preclude, upon the filing in the same 
     form and manner of such policy form with the applicable State 
     authority in such other State, the approval of the filing in 
     such other State.
       ``(3) Nothing in subsection (b)(6)(E) or the preceding 
     provisions of this subsection shall be construed, with 
     respect to health insurance issuers or health insurance 
     coverage, to supersede or impair the law of any State--
       ``(A) providing solvency standards or similar standards 
     regarding the adequacy of insurer capital, surplus, reserves, 
     or contributions, or
       ``(B) relating to prompt payment of claims.
       ``(4) For additional provisions relating to association 
     health plans, see subsections (a)(2)(B) and (b) of section 
     805.
       ``(5) For purposes of this subsection, the term 
     `association health plan' has the meaning provided in section 
     801(a), and the terms `health insurance coverage', 
     `participating employer', and `health insurance issuer' have 
     the meanings provided such terms in section 812, 
     respectively.''.
       (3) Section 514(b)(6)(A) of such Act (29 U.S.C. 
     1144(b)(6)(A)) is amended--
       (A) in clause (i)(II), by striking ``and'' at the end;
       (B) in clause (ii), by inserting ``and which does not 
     provide medical care (within the meaning of section 
     733(a)(2)),'' after ``arrangement,'', and by striking 
     ``title.'' and inserting ``title, and''; and
       (C) by adding at the end the following new clause:
       ``(iii) subject to subparagraph (E), in the case of any 
     other employee welfare benefit plan which is a multiple 
     employer welfare arrangement and which provides medical care 
     (within the meaning of section 733(a)(2)), any law of any 
     State which regulates insurance may apply.''.
       (4) Section 514(e) of such Act (as redesignated by 
     paragraph (2)(C)) is amended--
       (A) by striking ``Nothing'' and inserting ``(1) Except as 
     provided in paragraph (2), nothing''; and
       (B) by adding at the end the following new paragraph:
       ``(2) Nothing in any other provision of law enacted on or 
     after the date of the enactment of the Small Business Health 
     Fairness Act of 2009 shall be construed to alter, amend, 
     modify, invalidate, impair, or supersede any provision of 
     this title, except by specific cross-reference to the 
     affected section.''.
       (c) Plan Sponsor.--Section 3(16)(B) of such Act (29 U.S.C. 
     102(16)(B)) is amended by adding at the end the following new 
     sentence: ``Such term also includes a person serving as the 
     sponsor of an association health plan under part 8.''.
       (d) Disclosure of Solvency Protections Related to Self-
     Insured and Fully Insured Options Under Association Health 
     Plans.--Section 102(b) of such Act (29 U.S.C. 102(b)) is 
     amended by adding at the end the following: ``An association 
     health plan shall include in its summary plan description, in 
     connection with each benefit option, a description of the 
     form of solvency or guarantee fund protection secured 
     pursuant to this Act or applicable State law, if any.''.
       (e) Savings Clause.--Section 731(c) of such Act is amended 
     by inserting ``or part 8'' after ``this part''.
       (f) Report to the Congress Regarding Certification of Self-
     Insured Association Health Plans.--Not later than January 1, 
     2012, the Secretary of Labor shall report to the Committee on 
     Education and the Workforce of the House of Representatives 
     and the Committee on Health, Education, Labor, and Pensions 
     of the Senate the effect association health plans have had, 
     if any, on reducing the number of uninsured individuals.
       (g) Clerical Amendment.--The table of contents in section 1 
     of the Employee Retirement Income Security Act of 1974 is 
     amended by inserting after the item relating to section 734 
     the following new items:

           ``Part 8--Rules Governing Association Health Plans

``801. Association health plans.
``802. Certification of association health plans.
``803. Requirements relating to sponsors and boards of trustees.
``804. Participation and coverage requirements.
``805. Other requirements relating to plan documents, contribution 
              rates, and benefit options.
``806. Maintenance of reserves and provisions for solvency for plans 
              providing health benefits in addition to health insurance 
              coverage.
``807. Requirements for application and related requirements.
``808. Notice requirements for voluntary termination.
``809. Corrective actions and mandatory termination.
``810. Trusteeship by the Secretary of insolvent association health 
              plans providing health benefits in addition to health 
              insurance coverage.
``811. State assessment authority.
``812. Definitions and rules of construction.''.

     SEC. 202. CLARIFICATION OF TREATMENT OF SINGLE EMPLOYER 
                   ARRANGEMENTS.

       Section 3(40)(B) of the Employee Retirement Income Security 
     Act of 1974 (29 U.S.C. 1002(40)(B)) is amended--
       (1) in clause (i), by inserting after ``control group,'' 
     the following: ``except that, in any case in which the 
     benefit referred to in subparagraph (A) consists of medical 
     care (as defined in section 812(a)(2)), two or more trades or 
     businesses, whether or not incorporated, shall be deemed a 
     single employer for any plan year of such plan, or any fiscal 
     year of such other arrangement, if such

[[Page 27545]]

     trades or businesses are within the same control group during 
     such year or at any time during the preceding 1-year 
     period,'';
       (2) in clause (iii), by striking ``(iii) the 
     determination'' and inserting the following:
       ``(iii)(I) in any case in which the benefit referred to in 
     subparagraph (A) consists of medical care (as defined in 
     section 812(a)(2)), the determination of whether a trade or 
     business is under `common control' with another trade or 
     business shall be determined under regulations of the 
     Secretary applying principles consistent and coextensive with 
     the principles applied in determining whether employees of 
     two or more trades or businesses are treated as employed by a 
     single employer under section 4001(b), except that, for 
     purposes of this paragraph, an interest of greater than 25 
     percent may not be required as the minimum interest necessary 
     for common control, or
       ``(II) in any other case, the determination'';
       (3) by redesignating clauses (iv) and (v) as clauses (v) 
     and (vi), respectively; and
       (4) by inserting after clause (iii) the following new 
     clause:
       ``(iv) in any case in which the benefit referred to in 
     subparagraph (A) consists of medical care (as defined in 
     section 812(a)(2)), in determining, after the application of 
     clause (i), whether benefits are provided to employees of two 
     or more employers, the arrangement shall be treated as having 
     only one participating employer if, after the application of 
     clause (i), the number of individuals who are employees and 
     former employees of any one participating employer and who 
     are covered under the arrangement is greater than 75 percent 
     of the aggregate number of all individuals who are employees 
     or former employees of participating employers and who are 
     covered under the arrangement,''.

     SEC. 203. ENFORCEMENT PROVISIONS RELATING TO ASSOCIATION 
                   HEALTH PLANS.

       (a) Criminal Penalties for Certain Willful 
     Misrepresentations.--Section 501 of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. 1131) is amended--
       (1) by inserting ``(a)'' after ``Sec. 501.''; and
       (2) by adding at the end the following new subsection:
       ``(b) Any person who willfully falsely represents, to any 
     employee, any employee's beneficiary, any employer, the 
     Secretary, or any State, a plan or other arrangement 
     established or maintained for the purpose of offering or 
     providing any benefit described in section 3(1) to employees 
     or their beneficiaries as--
       ``(1) being an association health plan which has been 
     certified under part 8;
       ``(2) having been established or maintained under or 
     pursuant to one or more collective bargaining agreements 
     which are reached pursuant to collective bargaining described 
     in section 8(d) of the National Labor Relations Act (29 
     U.S.C. 158(d)) or paragraph Fourth of section 2 of the 
     Railway Labor Act (45 U.S.C. 152, paragraph Fourth) or which 
     are reached pursuant to labor-management negotiations under 
     similar provisions of State public employee relations laws; 
     or
       ``(3) being a plan or arrangement described in section 
     3(40)(A)(i),

     shall, upon conviction, be imprisoned not more than 5 years, 
     be fined under title 18, United States Code, or both.''.
       (b) Cease Activities Orders.--Section 502 of such Act (29 
     U.S.C. 1132) is amended by adding at the end the following 
     new subsection:
       ``(n) Association Health Plan Cease and Desist Orders.--
       ``(1) In general.--Subject to paragraph (2), upon 
     application by the Secretary showing the operation, 
     promotion, or marketing of an association health plan (or 
     similar arrangement providing benefits consisting of medical 
     care (as defined in section 733(a)(2))) that--
       ``(A) is not certified under part 8, is subject under 
     section 514(b)(6) to the insurance laws of any State in which 
     the plan or arrangement offers or provides benefits, and is 
     not licensed, registered, or otherwise approved under the 
     insurance laws of such State; or
       ``(B) is an association health plan certified under part 8 
     and is not operating in accordance with the requirements 
     under part 8 for such certification,

     a district court of the United States shall enter an order 
     requiring that the plan or arrangement cease activities.
       ``(2) Exception.--Paragraph (1) shall not apply in the case 
     of an association health plan or other arrangement if the 
     plan or arrangement shows that--
       ``(A) all benefits under it referred to in paragraph (1) 
     consist of health insurance coverage; and
       ``(B) with respect to each State in which the plan or 
     arrangement offers or provides benefits, the plan or 
     arrangement is operating in accordance with applicable State 
     laws that are not superseded under section 514.
       ``(3) Additional equitable relief.--The court may grant 
     such additional equitable relief, including any relief 
     available under this title, as it deems necessary to protect 
     the interests of the public and of persons having claims for 
     benefits against the plan.''.
       (c) Responsibility for Claims Procedure.--Section 503 of 
     such Act (29 U.S.C. 1133) is amended by inserting ``(a) In 
     General.--'' before ``In accordance'', and by adding at the 
     end the following new subsection:
       ``(b) Association Health Plans.--The terms of each 
     association health plan which is or has been certified under 
     part 8 shall require the board of trustees or the named 
     fiduciary (as applicable) to ensure that the requirements of 
     this section are met in connection with claims filed under 
     the plan.''.

     SEC. 204. COOPERATION BETWEEN FEDERAL AND STATE AUTHORITIES.

       Section 506 of the Employee Retirement Income Security Act 
     of 1974 (29 U.S.C. 1136) is amended by adding at the end the 
     following new subsection:
       ``(d) Consultation With States With Respect to Association 
     Health Plans.--
       ``(1) Agreements with states.--The Secretary shall consult 
     with the State recognized under paragraph (2) with respect to 
     an association health plan regarding the exercise of--
       ``(A) the Secretary's authority under sections 502 and 504 
     to enforce the requirements for certification under part 8; 
     and
       ``(B) the Secretary's authority to certify association 
     health plans under part 8 in accordance with regulations of 
     the Secretary applicable to certification under part 8.
       ``(2) Recognition of primary domicile state.--In carrying 
     out paragraph (1), the Secretary shall ensure that only one 
     State will be recognized, with respect to any particular 
     association health plan, as the State with which consultation 
     is required. In carrying out this paragraph--
       ``(A) in the case of a plan which provides health insurance 
     coverage (as defined in section 812(a)(3)), such State shall 
     be the State with which filing and approval of a policy type 
     offered by the plan was initially obtained, and
       ``(B) in any other case, the Secretary shall take into 
     account the places of residence of the participants and 
     beneficiaries under the plan and the State in which the trust 
     is maintained.''.

     SEC. 205. EFFECTIVE DATE AND TRANSITIONAL AND OTHER RULES.

       (a) Effective Date.--The amendments made by this title 
     shall take effect 1 year after the date of the enactment of 
     this Act. The Secretary of Labor shall first issue all 
     regulations necessary to carry out the amendments made by 
     this title within 1 year after the date of the enactment of 
     this Act.
       (b) Treatment of Certain Existing Health Benefits 
     Programs.--
       (1) In general.--In any case in which, as of the date of 
     the enactment of this Act, an arrangement is maintained in a 
     State for the purpose of providing benefits consisting of 
     medical care for the employees and beneficiaries of its 
     participating employers, at least 200 participating employers 
     make contributions to such arrangement, such arrangement has 
     been in existence for at least 10 years, and such arrangement 
     is licensed under the laws of one or more States to provide 
     such benefits to its participating employers, upon the filing 
     with the applicable authority (as defined in section 
     812(a)(5) of the Employee Retirement Income Security Act of 
     1974 (as amended by this subtitle)) by the arrangement of an 
     application for certification of the arrangement under part 8 
     of subtitle B of title I of such Act--
       (A) such arrangement shall be deemed to be a group health 
     plan for purposes of title I of such Act;
       (B) the requirements of sections 801(a) and 803(a) of the 
     Employee Retirement Income Security Act of 1974 shall be 
     deemed met with respect to such arrangement;
       (C) the requirements of section 803(b) of such Act shall be 
     deemed met, if the arrangement is operated by a board of 
     directors which--
       (i) is elected by the participating employers, with each 
     employer having one vote; and
       (ii) has complete fiscal control over the arrangement and 
     which is responsible for all operations of the arrangement;
       (D) the requirements of section 804(a) of such Act shall be 
     deemed met with respect to such arrangement; and
       (E) the arrangement may be certified by any applicable 
     authority with respect to its operations in any State only if 
     it operates in such State on the date of certification.

     The provisions of this subsection shall cease to apply with 
     respect to any such arrangement at such time after the date 
     of the enactment of this Act as the applicable requirements 
     of this subsection are not met with respect to such 
     arrangement.
       (2) Definitions.--For purposes of this subsection, the 
     terms ``group health plan'', ``medical care'', and 
     ``participating employer'' shall have the meanings provided 
     in section 812 of the Employee Retirement Income Security Act 
     of 1974, except that the reference in paragraph (7) of such 
     section to an ``association health plan'' shall be deemed a 
     reference to an arrangement referred to in this subsection.

              TITLE II--TARGETED EFFORTS TO EXPAND ACCESS

     SEC. 211. EXTENDING COVERAGE OF DEPENDENTS.

       (a) Employee Retirement Income Security Act of 1974.--
       (1) In general.--Part 7 of subtitle B of title I of the 
     Employee Retirement Income Security Act of 1974 is amended by 
     inserting after section 2714 the following new section:

[[Page 27546]]



     ``SEC. 715. EXTENDING COVERAGE OF DEPENDENTS.

       ``(a) In General.--In the case of a group health plan, or 
     health insurance coverage offered in connection with a group 
     health plan, that treats as a beneficiary under the plan an 
     individual who is a dependent child of a participant or 
     beneficiary under the plan, the plan or coverage shall 
     continue to treat the individual as a dependent child without 
     regard to the individual's age through at least the end of 
     the plan year in which the individual turns an age specified 
     in the plan, but not less than 25 years of age.
       ``(b) Construction.--Nothing in this section shall be 
     construed as requiring a group health plan to provide 
     benefits for dependent children as beneficiaries under the 
     plan or to require a participant to elect coverage of 
     dependent children.''.
       (2) Clerical amendment.--The table of contents of such Act 
     is amended by inserting after the item relating to section 
     714 the following new item:

``Sec. 715. Extending coverage of dependents through plan year that 
              includes 25th birthday.''.

       (b) PHSA.--Title XXVII of the Public Health Service Act is 
     amended by inserting after section 2707 the following new 
     section:

     ``SEC. 2708. EXTENDING COVERAGE OF DEPENDENTS.

       ``(a) In General.--In the case of a group health plan, or 
     health insurance coverage offered in connection with a group 
     health plan, that treats as a beneficiary under the plan an 
     individual who is a dependent child of a participant or 
     beneficiary under the plan, the plan or coverage shall 
     continue to treat the individual as a dependent child without 
     regard to the individual's age through at least the end of 
     the plan year in which the individual turns an age specified 
     in the plan, but not less than 25 years of age.
       ``(b) Construction.--Nothing in this section shall be 
     construed as requiring a group health plan to provide 
     benefits for dependent children as beneficiaries under the 
     plan or to require a participant to elect coverage of 
     dependent children.''.
       (c) IRC.--
       (1) In general.--Subchapter B of chapter 100 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new section:

     ``SEC. 9814. EXTENDING COVERAGE OF DEPENDENTS.

       ``(a) In General.--In the case of a group health plan that 
     treats as a beneficiary under the plan an individual who is a 
     dependent child of a participant or beneficiary under the 
     plan, the plan shall continue to treat the individual as a 
     dependent child without regard to the individual's age 
     through at least the end of the plan year in which the 
     individual turns an age specified in the plan, but not less 
     than 25 years of age.
       ``(b) Construction.--Nothing in this section shall be 
     construed as requiring a group health plan to provide 
     coverage for dependent children as beneficiaries under the 
     plan or to require a participant to elect coverage of 
     dependent children.''.
       (2) Clerical amendment.--The table of sections in such 
     subchapter is amended by adding at the end the following new 
     item:

``Sec. 9814. Extending coverage of dependents through plan year that 
              includes 25th birthday.''.

       (d) Effective Date.--The amendments made by this section 
     shall apply to group health plans for plan years beginning 
     more than 3 months after the date of the enactment of this 
     Act and shall apply to individuals who are dependent children 
     under a group health plan, or health insurance coverage 
     offered in connection with such a plan, on or after such 
     date.

     SEC. 212. ALLOWING AUTO-ENROLLMENT FOR EMPLOYER SPONSORED 
                   COVERAGE.

       (a) In General.--No State shall establish a law that 
     prevents an employer from instituting auto-enrollment for 
     coverage of a participant or beneficiary, including current 
     employees, under a group health plan, or health insurance 
     coverage offered in connection with such a plan, so long as 
     the participant or beneficiary has the option of declining 
     such coverage.
       (b) Autoenrollment.--
       (1) Notice required.--Employers with auto-enrollment under 
     a group health plan or health insurance coverage shall 
     provide annual notification, within a reasonable period 
     before the beginning of each plan year, to each employee 
     eligible to participate in the plan. The notice shall explain 
     the employee contribution to such plan and the employee's 
     right to decline coverage.
       (2) Treatment of non-action.--After a reasonable period of 
     time after receipt of the notice, if an employee fails to 
     make an affirmative declaration declining coverage, then such 
     an employee may be enrolled in the group health plan or 
     health insurance coverage offered in connection with such a 
     plan.''
       (c) Construction.--Nothing in this section shall be 
     construed to supersede State law which establishes, 
     implements, or continues in effect any standard or 
     requirement relating to employers in connection with payroll 
     or the sponsoring of employer sponsored health insurance 
     coverage except to the extent that such standard or 
     requirement prevents an employer from instituting the auto-
     enrollment described in subsection (a).

 TITLE III--EXPANDING CHOICES BY ALLOWING AMERICANS TO BUY HEALTH CARE 
                      COVERAGE ACROSS STATE LINES

     SEC. 221. INTERSTATE PURCHASING OF HEALTH INSURANCE.

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

``PART D--COOPERATIVE GOVERNING OF INDIVIDUAL HEALTH INSURANCE COVERAGE

     ``SEC. 2795. DEFINITIONS.

       ``In this part:
       ``(1) Primary state.--The term `primary State' means, with 
     respect to individual health insurance coverage offered by a 
     health insurance issuer, the State designated by the issuer 
     as the State whose covered laws shall govern the health 
     insurance issuer in the sale of such coverage under this 
     part. An issuer, with respect to a particular policy, may 
     only designate one such State as its primary State with 
     respect to all such coverage it offers. Such an issuer may 
     not change the designated primary State with respect to 
     individual health insurance coverage once the policy is 
     issued, except that such a change may be made upon renewal of 
     the policy. With respect to such designated State, the issuer 
     is deemed to be doing business in that State.
       ``(2) Secondary state.--The term `secondary State' means, 
     with respect to individual health insurance coverage offered 
     by a health insurance issuer, any State that is not the 
     primary State. In the case of a health insurance issuer that 
     is selling a policy in, or to a resident of, a secondary 
     State, the issuer is deemed to be doing business in that 
     secondary State.
       ``(3) Health insurance issuer.--The term `health insurance 
     issuer' has the meaning given such term in section 
     2791(b)(2), except that such an issuer must be licensed in 
     the primary State and be qualified to sell individual health 
     insurance coverage in that State.
       ``(4) Individual health insurance coverage.--The term 
     `individual health insurance coverage' means health insurance 
     coverage offered in the individual market, as defined in 
     section 2791(e)(1).
       ``(5) Applicable state authority.--The term `applicable 
     State authority' means, with respect to a health insurance 
     issuer in a State, the State insurance commissioner or 
     official or officials designated by the State to enforce the 
     requirements of this title for the State with respect to the 
     issuer.
       ``(6) Hazardous financial condition.--The term `hazardous 
     financial condition' means that, based on its present or 
     reasonably anticipated financial condition, a health 
     insurance issuer is unlikely to be able--
       ``(A) to meet obligations to policyholders with respect to 
     known claims and reasonably anticipated claims; or
       ``(B) to pay other obligations in the normal course of 
     business.
       ``(7) Covered laws.--
       ``(A) In general.--The term `covered laws' means the laws, 
     rules, regulations, agreements, and orders governing the 
     insurance business pertaining to--
       ``(i) individual health insurance coverage issued by a 
     health insurance issuer;
       ``(ii) the offer, sale, rating (including medical 
     underwriting), renewal, and issuance of individual health 
     insurance coverage to an individual;
       ``(iii) the provision to an individual in relation to 
     individual health insurance coverage of health care and 
     insurance related services;
       ``(iv) the provision to an individual in relation to 
     individual health insurance coverage of management, 
     operations, and investment activities of a health insurance 
     issuer; and
       ``(v) the provision to an individual in relation to 
     individual health insurance coverage of loss control and 
     claims administration for a health insurance issuer with 
     respect to liability for which the issuer provides insurance.
       ``(B) Exception.--Such term does not include any law, rule, 
     regulation, agreement, or order governing the use of care or 
     cost management techniques, including any requirement related 
     to provider contracting, network access or adequacy, health 
     care data collection, or quality assurance.
       ``(8) State.--The term `State' means the 50 States and 
     includes the District of Columbia, Puerto Rico, the Virgin 
     Islands, Guam, American Samoa, and the Northern Mariana 
     Islands.
       ``(9) Unfair claims settlement practices.--The term `unfair 
     claims settlement practices' means only the following 
     practices:
       ``(A) Knowingly misrepresenting to claimants and insured 
     individuals relevant facts or policy provisions relating to 
     coverage at issue.
       ``(B) Failing to acknowledge with reasonable promptness 
     pertinent communications with respect to claims arising under 
     policies.
       ``(C) Failing to adopt and implement reasonable standards 
     for the prompt investigation and settlement of claims arising 
     under policies.
       ``(D) Failing to effectuate prompt, fair, and equitable 
     settlement of claims submitted in which liability has become 
     reasonably clear.

[[Page 27547]]

       ``(E) Refusing to pay claims without conducting a 
     reasonable investigation.
       ``(F) Failing to affirm or deny coverage of claims within a 
     reasonable period of time after having completed an 
     investigation related to those claims.
       ``(G) A pattern or practice of compelling insured 
     individuals or their beneficiaries to institute suits to 
     recover amounts due under its policies by offering 
     substantially less than the amounts ultimately recovered in 
     suits brought by them.
       ``(H) A pattern or practice of attempting to settle or 
     settling claims for less than the amount that a reasonable 
     person would believe the insured individual or his or her 
     beneficiary was entitled by reference to written or printed 
     advertising material accompanying or made part of an 
     application.
       ``(I) Attempting to settle or settling claims on the basis 
     of an application that was materially altered without notice 
     to, or knowledge or consent of, the insured.
       ``(J) Failing to provide forms necessary to present claims 
     within 15 calendar days of a requests with reasonable 
     explanations regarding their use.
       ``(K) Attempting to cancel a policy in less time than that 
     prescribed in the policy or by the law of the primary State.
       ``(10) Fraud and abuse.--The term `fraud and abuse' means 
     an act or omission committed by a person who, knowingly and 
     with intent to defraud, commits, or conceals any material 
     information concerning, one or more of the following:
       ``(A) Presenting, causing to be presented or preparing with 
     knowledge or belief that it will be presented to or by an 
     insurer, a reinsurer, broker or its agent, false information 
     as part of, in support of or concerning a fact material to 
     one or more of the following:
       ``(i) An application for the issuance or renewal of an 
     insurance policy or reinsurance contract.
       ``(ii) The rating of an insurance policy or reinsurance 
     contract.
       ``(iii) A claim for payment or benefit pursuant to an 
     insurance policy or reinsurance contract.
       ``(iv) Premiums paid on an insurance policy or reinsurance 
     contract.
       ``(v) Payments made in accordance with the terms of an 
     insurance policy or reinsurance contract.
       ``(vi) A document filed with the commissioner or the chief 
     insurance regulatory official of another jurisdiction.
       ``(vii) The financial condition of an insurer or reinsurer.
       ``(viii) The formation, acquisition, merger, 
     reconsolidation, dissolution or withdrawal from one or more 
     lines of insurance or reinsurance in all or part of a State 
     by an insurer or reinsurer.
       ``(ix) The issuance of written evidence of insurance.
       ``(x) The reinstatement of an insurance policy.
       ``(B) Solicitation or acceptance of new or renewal 
     insurance risks on behalf of an insurer reinsurer or other 
     person engaged in the business of insurance by a person who 
     knows or should know that the insurer or other person 
     responsible for the risk is insolvent at the time of the 
     transaction.
       ``(C) Transaction of the business of insurance in violation 
     of laws requiring a license, certificate of authority or 
     other legal authority for the transaction of the business of 
     insurance.
       ``(D) Attempt to commit, aiding or abetting in the 
     commission of, or conspiracy to commit the acts or omissions 
     specified in this paragraph.

     ``SEC. 2796. APPLICATION OF LAW.

       ``(a) In General.--The covered laws of the primary State 
     shall apply to individual health insurance coverage offered 
     by a health insurance issuer in the primary State and in any 
     secondary State, but only if the coverage and issuer comply 
     with the conditions of this section with respect to the 
     offering of coverage in any secondary State.
       ``(b) Exemptions From Covered Laws in a Secondary State.--
     Except as provided in this section, a health insurance issuer 
     with respect to its offer, sale, rating (including medical 
     underwriting), renewal, and issuance of individual health 
     insurance coverage in any secondary State is exempt from any 
     covered laws of the secondary State (and any rules, 
     regulations, agreements, or orders sought or issued by such 
     State under or related to such covered laws) to the extent 
     that such laws would--
       ``(1) make unlawful, or regulate, directly or indirectly, 
     the operation of the health insurance issuer operating in the 
     secondary State, except that any secondary State may require 
     such an issuer--
       ``(A) to pay, on a nondiscriminatory basis, applicable 
     premium and other taxes (including high risk pool 
     assessments) which are levied on insurers and surplus lines 
     insurers, brokers, or policyholders under the laws of the 
     State;
       ``(B) to register with and designate the State insurance 
     commissioner as its agent solely for the purpose of receiving 
     service of legal documents or process;
       ``(C) to submit to an examination of its financial 
     condition by the State insurance commissioner in any State in 
     which the issuer is doing business to determine the issuer's 
     financial condition, if--
       ``(i) the State insurance commissioner of the primary State 
     has not done an examination within the period recommended by 
     the National Association of Insurance Commissioners; and
       ``(ii) any such examination is conducted in accordance with 
     the examiners' handbook of the National Association of 
     Insurance Commissioners and is coordinated to avoid 
     unjustified duplication and unjustified repetition;
       ``(D) to comply with a lawful order issued--
       ``(i) in a delinquency proceeding commenced by the State 
     insurance commissioner if there has been a finding of 
     financial impairment under subparagraph (C); or
       ``(ii) in a voluntary dissolution proceeding;
       ``(E) to comply with an injunction issued by a court of 
     competent jurisdiction, upon a petition by the State 
     insurance commissioner alleging that the issuer is in 
     hazardous financial condition;
       ``(F) to participate, on a nondiscriminatory basis, in any 
     insurance insolvency guaranty association or similar 
     association to which a health insurance issuer in the State 
     is required to belong;
       ``(G) to comply with any State law regarding fraud and 
     abuse (as defined in section 2795(10)), except that if the 
     State seeks an injunction regarding the conduct described in 
     this subparagraph, such injunction must be obtained from a 
     court of competent jurisdiction;
       ``(H) to comply with any State law regarding unfair claims 
     settlement practices (as defined in section 2795(9)); or
       ``(I) to comply with the applicable requirements for 
     independent review under section 2798 with respect to 
     coverage offered in the State;
       ``(2) require any individual health insurance coverage 
     issued by the issuer to be countersigned by an insurance 
     agent or broker residing in that Secondary State; or
       ``(3) otherwise discriminate against the issuer issuing 
     insurance in both the primary State and in any secondary 
     State.
       ``(c) Clear and Conspicuous Disclosure.--A health insurance 
     issuer shall provide the following notice, in 12-point bold 
     type, in any insurance coverage offered in a secondary State 
     under this part by such a health insurance issuer and at 
     renewal of the policy, with the 5 blank spaces therein being 
     appropriately filled with the name of the health insurance 
     issuer, the name of primary State, the name of the secondary 
     State, the name of the secondary State, and the name of the 
     secondary State, respectively, for the coverage concerned:

     this policy is issued by _____ AND IS GOVERNED BY THE LAWS 
     AND REGULATIONS OF THE STATE OF _____, AND IT HAS MET ALL THE 
     LAWS OF THAT STATE AS DETERMINED BY THAT STATE'S DEPARTMENT 
     OF INSURANCE. THIS POLICY MAY BE LESS EXPENSIVE THAN OTHERS 
     BECAUSE IT IS NOT SUBJECT TO ALL OF THE INSURANCE LAWS AND 
     REGULATIONS OF THE STATE OF _____, INCLUDING COVERAGE OF SOME 
     SERVICES OR BENEFITS MANDATED BY THE LAW OF THE STATE OF 
     _____. ADDITIONALLY, THIS POLICY IS NOT SUBJECT TO ALL OF THE 
     CONSUMER PROTECTION LAWS OR RESTRICTIONS ON RATE CHANGES OF 
     THE STATE OF _____. AS WITH ALL INSURANCE PRODUCTS, BEFORE 
     PURCHASING THIS POLICY, YOU SHOULD CAREFULLY REVIEW THE 
     POLICY AND DETERMINE WHAT HEALTH CARE SERVICES THE POLICY 
     COVERS AND WHAT BENEFITS IT PROVIDES, INCLUDING ANY 
     EXCLUSIONS, LIMITATIONS, OR CONDITIONS FOR SUCH SERVICES OR 
     BENEFITS.''.
       ``(d) Prohibition on Certain Reclassifications and Premium 
     Increases.--
       ``(1) In general.--For purposes of this section, a health 
     insurance issuer that provides individual health insurance 
     coverage to an individual under this part in a primary or 
     secondary State may not upon renewal--
       ``(A) move or reclassify the individual insured under the 
     health insurance coverage from the class such individual is 
     in at the time of issue of the contract based on the health-
     status related factors of the individual; or
       ``(B) increase the premiums assessed the individual for 
     such coverage based on a health status-related factor or 
     change of a health status-related factor or the past or 
     prospective claim experience of the insured individual.
       ``(2) Construction.--Nothing in paragraph (1) shall be 
     construed to prohibit a health insurance issuer--
       ``(A) from terminating or discontinuing coverage or a class 
     of coverage in accordance with subsections (b) and (c) of 
     section 2742;
       ``(B) from raising premium rates for all policy holders 
     within a class based on claims experience;
       ``(C) from changing premiums or offering discounted 
     premiums to individuals who engage in wellness activities at 
     intervals prescribed by the issuer, if such premium changes 
     or incentives--
       ``(i) are disclosed to the consumer in the insurance 
     contract;
       ``(ii) are based on specific wellness activities that are 
     not applicable to all individuals; and
       ``(iii) are not obtainable by all individuals to whom 
     coverage is offered;
       ``(D) from reinstating lapsed coverage; or

[[Page 27548]]

       ``(E) from retroactively adjusting the rates charged an 
     insured individual if the initial rates were set based on 
     material misrepresentation by the individual at the time of 
     issue.
       ``(e) Prior Offering of Policy in Primary State.--A health 
     insurance issuer may not offer for sale individual health 
     insurance coverage in a secondary State unless that coverage 
     is currently offered for sale in the primary State.
       ``(f) Licensing of Agents or Brokers for Health Insurance 
     Issuers.--Any State may require that a person acting, or 
     offering to act, as an agent or broker for a health insurance 
     issuer with respect to the offering of individual health 
     insurance coverage obtain a license from that State, with 
     commissions or other compensation subject to the provisions 
     of the laws of that State, except that a State may not impose 
     any qualification or requirement which discriminates against 
     a nonresident agent or broker.
       ``(g) Documents for Submission to State Insurance 
     Commissioner.--Each health insurance issuer issuing 
     individual health insurance coverage in both primary and 
     secondary States shall submit--
       ``(1) to the insurance commissioner of each State in which 
     it intends to offer such coverage, before it may offer 
     individual health insurance coverage in such State--
       ``(A) a copy of the plan of operation or feasibility study 
     or any similar statement of the policy being offered and its 
     coverage (which shall include the name of its primary State 
     and its principal place of business);
       ``(B) written notice of any change in its designation of 
     its primary State; and
       ``(C) written notice from the issuer of the issuer's 
     compliance with all the laws of the primary State; and
       ``(2) to the insurance commissioner of each secondary State 
     in which it offers individual health insurance coverage, a 
     copy of the issuer's quarterly financial statement submitted 
     to the primary State, which statement shall be certified by 
     an independent public accountant and contain a statement of 
     opinion on loss and loss adjustment expense reserves made 
     by--
       ``(A) a member of the American Academy of Actuaries; or
       ``(B) a qualified loss reserve specialist.
       ``(h) Power of Courts To Enjoin Conduct.--Nothing in this 
     section shall be construed to affect the authority of any 
     Federal or State court to enjoin--
       ``(1) the solicitation or sale of individual health 
     insurance coverage by a health insurance issuer to any person 
     or group who is not eligible for such insurance; or
       ``(2) the solicitation or sale of individual health 
     insurance coverage that violates the requirements of the law 
     of a secondary State which are described in subparagraphs (A) 
     through (H) of section 2796(b)(1).
       ``(i) Power of Secondary States To Take Administrative 
     Action.--Nothing in this section shall be construed to affect 
     the authority of any State to enjoin conduct in violation of 
     that State's laws described in section 2796(b)(1).
       ``(j) State Powers To Enforce State Laws.--
       ``(1) In general.--Subject to the provisions of subsection 
     (b)(1)(G) (relating to injunctions) and paragraph (2), 
     nothing in this section shall be construed to affect the 
     authority of any State to make use of any of its powers to 
     enforce the laws of such State with respect to which a health 
     insurance issuer is not exempt under subsection (b).
       ``(2) Courts of competent jurisdiction.--If a State seeks 
     an injunction regarding the conduct described in paragraphs 
     (1) and (2) of subsection (h), such injunction must be 
     obtained from a Federal or State court of competent 
     jurisdiction.
       ``(k) States' Authority To Sue.--Nothing in this section 
     shall affect the authority of any State to bring action in 
     any Federal or State court.
       ``(l) Generally Applicable Laws.--Nothing in this section 
     shall be construed to affect the applicability of State laws 
     generally applicable to persons or corporations.
       ``(m) Guaranteed Availability of Coverage to HIPAA Eligible 
     Individuals.--To the extent that a health insurance issuer is 
     offering coverage in a primary State that does not 
     accommodate residents of secondary States or does not provide 
     a working mechanism for residents of a secondary State, and 
     the issuer is offering coverage under this part in such 
     secondary State which has not adopted a qualified high risk 
     pool as its acceptable alternative mechanism (as defined in 
     section 2744(c)(2)), the issuer shall, with respect to any 
     individual health insurance coverage offered in a secondary 
     State under this part, comply with the guaranteed 
     availability requirements for eligible individuals in section 
     2741.

     ``SEC. 2797. PRIMARY STATE MUST MEET FEDERAL FLOOR BEFORE 
                   ISSUER MAY SELL INTO SECONDARY STATES.

       ``A health insurance issuer may not offer, sell, or issue 
     individual health insurance coverage in a secondary State if 
     the State insurance commissioner does not use a risk-based 
     capital formula for the determination of capital and surplus 
     requirements for all health insurance issuers.

     ``SEC. 2798. INDEPENDENT EXTERNAL APPEALS PROCEDURES.

       ``(a) Right to External Appeal.--A health insurance issuer 
     may not offer, sell, or issue individual health insurance 
     coverage in a secondary State under the provisions of this 
     title unless--
       ``(1) both the secondary State and the primary State have 
     legislation or regulations in place establishing an 
     independent review process for individuals who are covered by 
     individual health insurance coverage, or
       ``(2) in any case in which the requirements of subparagraph 
     (A) are not met with respect to the either of such States, 
     the issuer provides an independent review mechanism 
     substantially identical (as determined by the applicable 
     State authority of such State) to that prescribed in the 
     `Health Carrier External Review Model Act' of the National 
     Association of Insurance Commissioners for all individuals 
     who purchase insurance coverage under the terms of this part, 
     except that, under such mechanism, the review is conducted by 
     an independent medical reviewer, or a panel of such 
     reviewers, with respect to whom the requirements of 
     subsection (b) are met.
       ``(b) Qualifications of Independent Medical Reviewers.--In 
     the case of any independent review mechanism referred to in 
     subsection (a)(2)--
       ``(1) In general.--In referring a denial of a claim to an 
     independent medical reviewer, or to any panel of such 
     reviewers, to conduct independent medical review, the issuer 
     shall ensure that--
       ``(A) each independent medical reviewer meets the 
     qualifications described in paragraphs (2) and (3);
       ``(B) with respect to each review, each reviewer meets the 
     requirements of paragraph (4) and the reviewer, or at least 1 
     reviewer on the panel, meets the requirements described in 
     paragraph (5); and
       ``(C) compensation provided by the issuer to each reviewer 
     is consistent with paragraph (6).
       ``(2) Licensure and expertise.--Each independent medical 
     reviewer shall be a physician (allopathic or osteopathic) or 
     health care professional who--
       ``(A) is appropriately credentialed or licensed in 1 or 
     more States to deliver health care services; and
       ``(B) typically treats the condition, makes the diagnosis, 
     or provides the type of treatment under review.
       ``(3) Independence.--
       ``(A) In general.--Subject to subparagraph (B), each 
     independent medical reviewer in a case shall--
       ``(i) not be a related party (as defined in paragraph (7));
       ``(ii) not have a material familial, financial, or 
     professional relationship with such a party; and
       ``(iii) not otherwise have a conflict of interest with such 
     a party (as determined under regulations).
       ``(B) Exception.--Nothing in subparagraph (A) shall be 
     construed to--
       ``(i) prohibit an individual, solely on the basis of 
     affiliation with the issuer, from serving as an independent 
     medical reviewer if--

       ``(I) a non-affiliated individual is not reasonably 
     available;
       ``(II) the affiliated individual is not involved in the 
     provision of items or services in the case under review;
       ``(III) the fact of such an affiliation is disclosed to the 
     issuer and the enrollee (or authorized representative) and 
     neither party objects; and
       ``(IV) the affiliated individual is not an employee of the 
     issuer and does not provide services exclusively or primarily 
     to or on behalf of the issuer;

       ``(ii) prohibit an individual who has staff privileges at 
     the institution where the treatment involved takes place from 
     serving as an independent medical reviewer merely on the 
     basis of such affiliation if the affiliation is disclosed to 
     the issuer and the enrollee (or authorized representative), 
     and neither party objects; or
       ``(iii) prohibit receipt of compensation by an independent 
     medical reviewer from an entity if the compensation is 
     provided consistent with paragraph (6).
       ``(4) Practicing health care professional in same field.--
       ``(A) In general.--In a case involving treatment, or the 
     provision of items or services--
       ``(i) by a physician, a reviewer shall be a practicing 
     physician (allopathic or osteopathic) of the same or similar 
     specialty, as a physician who, acting within the appropriate 
     scope of practice within the State in which the service is 
     provided or rendered, typically treats the condition, makes 
     the diagnosis, or provides the type of treatment under 
     review; or
       ``(ii) by a non-physician health care professional, the 
     reviewer, or at least 1 member of the review panel, shall be 
     a practicing non-physician health care professional of the 
     same or similar specialty as the non-physician health care 
     professional who, acting within the appropriate scope of 
     practice within the State in which the service is provided or 
     rendered, typically treats the condition, makes the 
     diagnosis, or provides the type of treatment under review.
       ``(B) Practicing defined.--For purposes of this paragraph, 
     the term `practicing' means, with respect to an individual 
     who is a physician or other health care professional, that

[[Page 27549]]

     the individual provides health care services to individual 
     patients on average at least 2 days per week.
       ``(5) Pediatric expertise.--In the case of an external 
     review relating to a child, a reviewer shall have expertise 
     under paragraph (2) in pediatrics.
       ``(6) Limitations on reviewer compensation.--Compensation 
     provided by the issuer to an independent medical reviewer in 
     connection with a review under this section shall--
       ``(A) not exceed a reasonable level; and
       ``(B) not be contingent on the decision rendered by the 
     reviewer.
       ``(7) Related party defined.--For purposes of this section, 
     the term `related party' means, with respect to a denial of a 
     claim under a coverage relating to an enrollee, any of the 
     following:
       ``(A) The issuer involved, or any fiduciary, officer, 
     director, or employee of the issuer.
       ``(B) The enrollee (or authorized representative).
       ``(C) The health care professional that provides the items 
     or services involved in the denial.
       ``(D) The institution at which the items or services (or 
     treatment) involved in the denial are provided.
       ``(E) The manufacturer of any drug or other item that is 
     included in the items or services involved in the denial.
       ``(F) Any other party determined under any regulations to 
     have a substantial interest in the denial involved.
       ``(8) Definitions.--For purposes of this subsection:
       ``(A) Enrollee.--The term `enrollee' means, with respect to 
     health insurance coverage offered by a health insurance 
     issuer, an individual enrolled with the issuer to receive 
     such coverage.
       ``(B) Health care professional.--The term `health care 
     professional' means an individual who is licensed, 
     accredited, or certified under State law to provide specified 
     health care services and who is operating within the scope of 
     such licensure, accreditation, or certification.

     ``SEC. 2799. ENFORCEMENT.

       ``(a) In General.--Subject to subsection (b), with respect 
     to specific individual health insurance coverage the primary 
     State for such coverage has sole jurisdiction to enforce the 
     primary State's covered laws in the primary State and any 
     secondary State.
       ``(b) Secondary State's Authority.--Nothing in subsection 
     (a) shall be construed to affect the authority of a secondary 
     State to enforce its laws as set forth in the exception 
     specified in section 2796(b)(1).
       ``(c) Court Interpretation.--In reviewing action initiated 
     by the applicable secondary State authority, the court of 
     competent jurisdiction shall apply the covered laws of the 
     primary State.
       ``(d) Notice of Compliance Failure.--In the case of 
     individual health insurance coverage offered in a secondary 
     State that fails to comply with the covered laws of the 
     primary State, the applicable State authority of the 
     secondary State may notify the applicable State authority of 
     the primary State.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to individual health insurance coverage offered, 
     issued, or sold after the date that is one year after the 
     date of the enactment of this Act.
       (c) GAO Ongoing Study and Reports.--
       (1) Study.--The Comptroller General of the United States 
     shall conduct an ongoing study concerning the effect of the 
     amendment made by subsection (a) on--
       (A) the number of uninsured and under-insured;
       (B) the availability and cost of health insurance policies 
     for individuals with preexisting medical conditions;
       (C) the availability and cost of health insurance policies 
     generally;
       (D) the elimination or reduction of different types of 
     benefits under health insurance policies offered in different 
     States; and
       (E) cases of fraud or abuse relating to health insurance 
     coverage offered under such amendment and the resolution of 
     such cases.
       (2) Annual reports.--The Comptroller General shall submit 
     to Congress an annual report, after the end of each of the 5 
     years following the effective date of the amendment made by 
     subsection (a), on the ongoing study conducted under 
     paragraph (1).

              TITLE IV--IMPROVING HEALTH SAVINGS ACCOUNTS

     SEC. 231. SAVER'S CREDIT FOR CONTRIBUTIONS TO HEALTH SAVINGS 
                   ACCOUNTS.

       (a) Allowance of Credit.--Subsection (a) of section 25B of 
     the Internal Revenue Code of 1986 is amended by inserting 
     ``aggregate qualified HSA contributions and'' after ``so much 
     of the''.
       (b) Qualified HSA Contributions.--Subsection (d) of section 
     25B of such Code is amended by redesignating paragraph (2) as 
     paragraph (3) and by inserting after paragraph (1) the 
     following new paragraph:
       ``(2) Qualified hsa contributions.--The term `qualified HSA 
     contribution' means, with respect to any taxable year, a 
     contribution of the eligible individual to a health savings 
     account (as defined in section 223(d)(1)) for which a 
     deduction is allowable under section 223(a) for such taxable 
     year.''.
       (c) Conforming Amendment.--The first sentence of section 
     25B(d)(3)(A) of such Code (as redesignated by subsection (b)) 
     is amended to read as follows: ``The aggregate qualified 
     retirement savings contributions determined under paragraph 
     (1) and qualified HSA contributions determined under 
     paragraph (2) shall be reduced (but not below zero) by the 
     aggregate distributions received by the individual during the 
     testing period from any entity of a type to which 
     contributions under paragraph (1) or paragraph (2) (as the 
     case may be) may be made.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to contributions made after December 31, 2009.

     SEC. 232. HSA FUNDS FOR PREMIUMS FOR HIGH DEDUCTIBLE HEALTH 
                   PLANS.

       (a) In General.--Subparagraph (C) of section 223(d)(2) of 
     the Internal Revenue Code of 1986 is amended by striking 
     ``or'' at the end of clause (iii), by striking the period at 
     the end of clause (iv) and inserting ``, or'', and by adding 
     at the end the following:
       ``(v) a high deductible health plan if--

       ``(I) such plan is not offered in connection with a group 
     health plan,
       ``(II) no portion of any premium (within the meaning of 
     applicable premium under section 4980B(f)(4)) for such plan 
     is excludable from gross income under section 106, and
       ``(III) the account beneficiary demonstrates, using 
     procedures deemed appropriate by the Secretary, that after 
     payment of the premium for such insurance the balance in the 
     health savings account is at least twice the minimum 
     deductible in effect under subsection (c)(2)(A)(i) which is 
     applicable to such plan.''.

       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to premiums for a high deductible health plan for 
     periods beginning after December 31, 2009.

     SEC. 233. REQUIRING GREATER COORDINATION BETWEEN HDHP 
                   ADMINISTRATORS AND HSA ACCOUNT ADMINISTRATORS 
                   SO THAT ENROLLEES CAN ENROLL IN BOTH AT THE 
                   SAME TIME.

       The Secretary of the Treasury, through the issuance of 
     regulations or other guidance, shall encourage administrators 
     of health plans and trustees of health savings accounts to 
     provide for simultaneous enrollment in high deductible health 
     plans and setup of health savings accounts.

     SEC. 234. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES INCURRED 
                   BEFORE ESTABLISHMENT OF ACCOUNT.

       (a) In General.--Subsection (d) of section 223 of the 
     Internal Revenue Code of 1986 is amended by redesignating 
     paragraph (4) as paragraph (5) and by inserting after 
     paragraph (3) the following new paragraph:
       ``(4) Certain medical expenses incurred before 
     establishment of account treated as qualified.--
       ``(A) In general.--For purposes of paragraph (2), an 
     expense shall not fail to be treated as a qualified medical 
     expense solely because such expense was incurred before the 
     establishment of the health savings account if such expense 
     was incurred during the 60-day period beginning on the date 
     on which the high deductible health plan is first effective.
       ``(B) Special rules.--For purposes of subparagraph (A)--
       ``(i) an individual shall be treated as an eligible 
     individual for any portion of a month for which the 
     individual is described in subsection (c)(1), determined 
     without regard to whether the individual is covered under a 
     high deductible health plan on the 1st day of such month, and
       ``(ii) the effective date of the health savings account is 
     deemed to be the date on which the high deductible health 
     plan is first effective after the date of the enactment of 
     this paragraph.''.
       (b) Effective Date.--The amendment made by this section 
     shall apply with respect to insurance purchased after the 
     date of the enactment of this Act in taxable years beginning 
     after such date.

           DIVISION C--ENACTING REAL MEDICAL LIABILITY REFORM

     SEC. 301. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

       The time for the commencement of a health care lawsuit 
     shall be 3 years after the date of manifestation of injury or 
     1 year after the claimant discovers, or through the use of 
     reasonable diligence should have discovered, the injury, 
     whichever occurs first. In no event shall the time for 
     commencement of a health care lawsuit exceed 3 years after 
     the date of manifestation of injury unless tolled for any of 
     the following--
       (1) upon proof of fraud;
       (2) intentional concealment; or
       (3) the presence of a foreign body, which has no 
     therapeutic or diagnostic purpose or effect, in the person of 
     the injured person.

     Actions by a minor shall be commenced within 3 years from the 
     date of the alleged manifestation of injury except that 
     actions by a minor under the full age of 6 years shall be 
     commenced within 3 years of manifestation of injury or prior 
     to the minor's 8th birthday, whichever provides a longer 
     period. Such time limitation shall be tolled for minors for 
     any period during which a parent or guardian and a health 
     care provider or health care organization have committed 
     fraud or collusion in the failure to bring an action on 
     behalf of the injured minor.

[[Page 27550]]



     SEC. 302. COMPENSATING PATIENT INJURY.

       (a) Unlimited Amount of Damages for Actual Economic Losses 
     in Health Care Lawsuits.--In any health care lawsuit, nothing 
     in this title shall limit a claimant's recovery of the full 
     amount of the available economic damages, notwithstanding the 
     limitation in subsection (b).
       (b) Additional Noneconomic Damages.--In any health care 
     lawsuit, the amount of noneconomic damages, if available, may 
     be as much as $250,000, regardless of the number of parties 
     against whom the action is brought or the number of separate 
     claims or actions brought with respect to the same injury.
       (c) No Discount of Award for Noneconomic Damages.--For 
     purposes of applying the limitation in subsection (b), future 
     noneconomic damages shall not be discounted to present value. 
     The jury shall not be informed about the maximum award for 
     noneconomic damages. An award for noneconomic damages in 
     excess of $250,000 shall be reduced either before the entry 
     of judgment, or by amendment of the judgment after entry of 
     judgment, and such reduction shall be made before accounting 
     for any other reduction in damages required by law. If 
     separate awards are rendered for past and future noneconomic 
     damages and the combined awards exceed $250,000, the future 
     noneconomic damages shall be reduced first.
       (d) Fair Share Rule.--In any health care lawsuit, each 
     party shall be liable for that party's several share of any 
     damages only and not for the share of any other person. Each 
     party shall be liable only for the amount of damages 
     allocated to such party in direct proportion to such party's 
     percentage of responsibility. Whenever a judgment of 
     liability is rendered as to any party, a separate judgment 
     shall be rendered against each such party for the amount 
     allocated to such party. For purposes of this section, the 
     trier of fact shall determine the proportion of 
     responsibility of each party for the claimant's harm.

     SEC. 303. MAXIMIZING PATIENT RECOVERY.

       (a) Court Supervision of Share of Damages Actually Paid to 
     Claimants.--In any health care lawsuit, the court shall 
     supervise the arrangements for payment of damages to protect 
     against conflicts of interest that may have the effect of 
     reducing the amount of damages awarded that are actually paid 
     to claimants. In particular, in any health care lawsuit in 
     which the attorney for a party claims a financial stake in 
     the outcome by virtue of a contingent fee, the court shall 
     have the power to restrict the payment of a claimant's damage 
     recovery to such attorney, and to redirect such damages to 
     the claimant based upon the interests of justice and 
     principles of equity. In no event shall the total of all 
     contingent fees for representing all claimants in a health 
     care lawsuit exceed the following limits:
       (1) 40 percent of the first $50,000 recovered by the 
     claimant(s).
       (2) 33\1/3\ percent of the next $50,000 recovered by the 
     claimant(s).
       (3) 25 percent of the next $500,000 recovered by the 
     claimant(s).
       (4) 15 percent of any amount by which the recovery by the 
     claimant(s) is in excess of $600,000.
       (b) Applicability.--The limitations in this section shall 
     apply whether the recovery is by judgment, settlement, 
     mediation, arbitration, or any other form of alternative 
     dispute resolution. In a health care lawsuit involving a 
     minor or incompetent person, a court retains the authority to 
     authorize or approve a fee that is less than the maximum 
     permitted under this section. The requirement for court 
     supervision in the first two sentences of subsection (a) 
     applies only in civil actions.

     SEC. 304. ADDITIONAL HEALTH BENEFITS.

       In any health care lawsuit involving injury or wrongful 
     death, any party may introduce evidence of collateral source 
     benefits. If a party elects to introduce such evidence, any 
     opposing party may introduce evidence of any amount paid or 
     contributed or reasonably likely to be paid or contributed in 
     the future by or on behalf of the opposing party to secure 
     the right to such collateral source benefits. No provider of 
     collateral source benefits shall recover any amount against 
     the claimant or receive any lien or credit against the 
     claimant's recovery or be equitably or legally subrogated to 
     the right of the claimant in a health care lawsuit involving 
     injury or wrongful death. This section shall apply to any 
     health care lawsuit that is settled as well as a health care 
     lawsuit that is resolved by a fact finder. This section shall 
     not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section 
     1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security 
     Act.

     SEC. 305. PUNITIVE DAMAGES.

       (a) In General.--Punitive damages may, if otherwise 
     permitted by applicable State or Federal law, be awarded 
     against any person in a health care lawsuit only if it is 
     proven by clear and convincing evidence that such person 
     acted with malicious intent to injure the claimant, or that 
     such person deliberately failed to avoid unnecessary injury 
     that such person knew the claimant was substantially certain 
     to suffer. In any health care lawsuit where no judgment for 
     compensatory damages is rendered against such person, no 
     punitive damages may be awarded with respect to the claim in 
     such lawsuit. No demand for punitive damages shall be 
     included in a health care lawsuit as initially filed. A court 
     may allow a claimant to file an amended pleading for punitive 
     damages only upon a motion by the claimant and after a 
     finding by the court, upon review of supporting and opposing 
     affidavits or after a hearing, after weighing the evidence, 
     that the claimant has established by a substantial 
     probability that the claimant will prevail on the claim for 
     punitive damages. At the request of any party in a health 
     care lawsuit, the trier of fact shall consider in a separate 
     proceeding--
       (1) whether punitive damages are to be awarded and the 
     amount of such award; and
       (2) the amount of punitive damages following a 
     determination of punitive liability.

     If a separate proceeding is requested, evidence relevant only 
     to the claim for punitive damages, as determined by 
     applicable State law, shall be inadmissible in any proceeding 
     to determine whether compensatory damages are to be awarded.
       (b) Determining Amount of Punitive Damages.--
       (1) Factors considered.--In determining the amount of 
     punitive damages, if awarded, in a health care lawsuit, the 
     trier of fact shall consider only the following--
       (A) the severity of the harm caused by the conduct of such 
     party;
       (B) the duration of the conduct or any concealment of it by 
     such party;
       (C) the profitability of the conduct to such party;
       (D) the number of products sold or medical procedures 
     rendered for compensation, as the case may be, by such party, 
     of the kind causing the harm complained of by the claimant;
       (E) any criminal penalties imposed on such party, as a 
     result of the conduct complained of by the claimant; and
       (F) the amount of any civil fines assessed against such 
     party as a result of the conduct complained of by the 
     claimant.
       (2) Maximum award.--The amount of punitive damages, if 
     awarded, in a health care lawsuit may be as much as $250,000 
     or as much as two times the amount of economic damages 
     awarded, whichever is greater. The jury shall not be informed 
     of this limitation.

     SEC. 306. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO 
                   CLAIMANTS IN HEALTH CARE LAWSUITS.

       (a) In General.--In any health care lawsuit, if an award of 
     future damages, without reduction to present value, equaling 
     or exceeding $50,000 is made against a party with sufficient 
     insurance or other assets to fund a periodic payment of such 
     a judgment, the court shall, at the request of any party, 
     enter a judgment ordering that the future damages be paid by 
     periodic payments. In any health care lawsuit, the court may 
     be guided by the Uniform Periodic Payment of Judgments Act 
     promulgated by the National Conference of Commissioners on 
     Uniform State Laws.
       (b) Applicability.--This section applies to all actions 
     which have not been first set for trial or retrial before the 
     effective date of this title.

     SEC. 307. DEFINITIONS.

       In this title:
       (1) Alternative dispute resolution system; adr.--The term 
     ``alternative dispute resolution system'' or ``ADR'' means a 
     system that provides for the resolution of health care 
     lawsuits in a manner other than through a civil action 
     brought in a State or Federal court.
       (2) Claimant.--The term ``claimant'' means any person who 
     brings a health care lawsuit, including a person who asserts 
     or claims a right to legal or equitable contribution, 
     indemnity, or subrogation, arising out of a health care 
     liability claim or action, and any person on whose behalf 
     such a claim is asserted or such an action is brought, 
     whether deceased, incompetent, or a minor.
       (3) Collateral source benefits.--The term ``collateral 
     source benefits'' means any amount paid or reasonably likely 
     to be paid in the future to or on behalf of the claimant, or 
     any service, product, or other benefit provided or reasonably 
     likely to be provided in the future to or on behalf of the 
     claimant, as a result of the injury or wrongful death, 
     pursuant to--
       (A) any State or Federal health, sickness, income-
     disability, accident, or workers' compensation law;
       (B) any health, sickness, income-disability, or accident 
     insurance that provides health benefits or income-disability 
     coverage;
       (C) any contract or agreement of any group, organization, 
     partnership, or corporation to provide, pay for, or reimburse 
     the cost of medical, hospital, dental, or income-disability 
     benefits; and
       (D) any other publicly or privately funded program.
       (4) Compensatory damages.--The term ``compensatory 
     damages'' means objectively verifiable monetary losses 
     incurred as a result of the provision of, use of, or payment 
     for (or failure to provide, use, or pay for) health care 
     services or medical products, such as past and future medical 
     expenses, loss of past and future earnings, cost of obtaining 
     domestic services, loss of employment, and loss of business 
     or employment opportunities, damages for physical and 
     emotional pain, suffering, inconvenience, physical 
     impairment, mental anguish, disfigurement, loss of enjoyment 
     of life, loss of

[[Page 27551]]

     society and companionship, loss of consortium (other than 
     loss of domestic service), hedonic damages, injury to 
     reputation, and all other nonpecuniary losses of any kind or 
     nature. The term ``compensatory damages'' includes economic 
     damages and noneconomic damages, as such terms are defined in 
     this section.
       (5) Contingent fee.--The term ``contingent fee'' includes 
     all compensation to any person or persons which is payable 
     only if a recovery is effected on behalf of one or more 
     claimants.
       (6) Economic damages.--The term ``economic damages'' means 
     objectively verifiable monetary losses incurred as a result 
     of the provision of, use of, or payment for (or failure to 
     provide, use, or pay for) health care services or medical 
     products, such as past and future medical expenses, loss of 
     past and future earnings, cost of obtaining domestic 
     services, loss of employment, and loss of business or 
     employment opportunities.
       (7) Health care lawsuit.--The term ``health care lawsuit'' 
     means any health care liability claim concerning the 
     provision of health care goods or services or any medical 
     product affecting interstate commerce, or any health care 
     liability action concerning the provision of health care 
     goods or services or any medical product affecting interstate 
     commerce, brought in a State or Federal court or pursuant to 
     an alternative dispute resolution system, against a health 
     care provider, a health care organization, or the 
     manufacturer, distributor, supplier, marketer, promoter, or 
     seller of a medical product, regardless of the theory of 
     liability on which the claim is based, or the number of 
     claimants, plaintiffs, defendants, or other parties, or the 
     number of claims or causes of action, in which the claimant 
     alleges a health care liability claim. Such term does not 
     include a claim or action which is based on criminal 
     liability; which seeks civil fines or penalties paid to 
     Federal, State, or local government; or which is grounded in 
     antitrust.
       (8) Health care liability action.--The term ``health care 
     liability action'' means a civil action brought in a State or 
     Federal court or pursuant to an alternative dispute 
     resolution system, against a health care provider, a health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     regardless of the theory of liability on which the claim is 
     based, or the number of plaintiffs, defendants, or other 
     parties, or the number of causes of action, in which the 
     claimant alleges a health care liability claim.
       (9) Health care liability claim.--The term ``health care 
     liability claim'' means a demand by any person, whether or 
     not pursuant to ADR, against a health care provider, health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     including, but not limited to, third-party claims, cross-
     claims, counter-claims, or contribution claims, which are 
     based upon the provision of, use of, or payment for (or the 
     failure to provide, use, or pay for) health care services or 
     medical products, regardless of the theory of liability on 
     which the claim is based, or the number of plaintiffs, 
     defendants, or other parties, or the number of causes of 
     action.
       (10) Health care organization.--The term ``health care 
     organization'' means any person or entity which is obligated 
     to provide or pay for health benefits under any health plan, 
     including any person or entity acting under a contract or 
     arrangement with a health care organization to provide or 
     administer any health benefit.
       (11) Health care provider.--The term ``health care 
     provider'' means any person or entity required by State or 
     Federal laws or regulations to be licensed, registered, or 
     certified to provide health care services, and being either 
     so licensed, registered, or certified, or exempted from such 
     requirement by other statute or regulation.
       (12) Health care goods or services.--The term ``health care 
     goods or services'' means any goods or services provided by a 
     health care organization, provider, or by any individual 
     working under the supervision of a health care provider, that 
     relates to the diagnosis, prevention, or treatment of any 
     human disease or impairment, or the assessment or care of the 
     health of human beings.
       (13) Malicious intent to injure.--The term ``malicious 
     intent to injure'' means intentionally causing or attempting 
     to cause physical injury other than providing health care 
     goods or services.
       (14) Medical product.--The term ``medical product'' means a 
     drug, device, or biological product intended for humans, and 
     the terms ``drug'', ``device'', and ``biological product'' 
     have the meanings given such terms in sections 201(g)(1) and 
     201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 
     321(g)(1) and (h)) and section 351(a) of the Public Health 
     Service Act (42 U.S.C. 262(a)), respectively, including any 
     component or raw material used therein, but excluding health 
     care services.
       (15) Noneconomic damages.--The term ``noneconomic damages'' 
     means damages for physical and emotional pain, suffering, 
     inconvenience, physical impairment, mental anguish, 
     disfigurement, loss of enjoyment of life, loss of society and 
     companionship, loss of consortium (other than loss of 
     domestic service), hedonic damages, injury to reputation, and 
     all other nonpecuniary losses of any kind or nature.
       (16) Punitive damages.--The term ``punitive damages'' means 
     damages awarded, for the purpose of punishment or deterrence, 
     and not solely for compensatory purposes, against a health 
     care provider, health care organization, or a manufacturer, 
     distributor, or supplier of a medical product. Punitive 
     damages are neither economic nor noneconomic damages.
       (17) Recovery.--The term ``recovery'' means the net sum 
     recovered after deducting any disbursements or costs incurred 
     in connection with prosecution or settlement of the claim, 
     including all costs paid or advanced by any person. Costs of 
     health care incurred by the plaintiff and the attorneys' 
     office overhead costs or charges for legal services are not 
     deductible disbursements or costs for such purpose.
       (18) State.--The term ``State'' means each of the several 
     States, the District of Columbia, the Commonwealth of Puerto 
     Rico, the Virgin Islands, Guam, American Samoa, the Northern 
     Mariana Islands, the Trust Territory of the Pacific Islands, 
     and any other territory or possession of the United States, 
     or any political subdivision thereof.

     SEC. 308. EFFECT ON OTHER LAWS.

       (a) Vaccine Injury.--
       (1) To the extent that title XXI of the Public Health 
     Service Act establishes a Federal rule of law applicable to a 
     civil action brought for a vaccine-related injury or death--
       (A) this title does not affect the application of the rule 
     of law to such an action; and
       (B) any rule of law prescribed by this title in conflict 
     with a rule of law of such title XXI shall not apply to such 
     action.
       (2) If there is an aspect of a civil action brought for a 
     vaccine-related injury or death to which a Federal rule of 
     law under title XXI of the Public Health Service Act does not 
     apply, then this title or otherwise applicable law (as 
     determined under this title) will apply to such aspect of 
     such action.
       (b) Other Federal Law.--Except as provided in this section, 
     nothing in this title shall be deemed to affect any defense 
     available to a defendant in a health care lawsuit or action 
     under any other provision of Federal law.

     SEC. 309. STATE FLEXIBILITY AND PROTECTION OF STATES' RIGHTS.

       (a) Health Care Lawsuits.--The provisions governing health 
     care lawsuits set forth in this title preempt, subject to 
     subsections (b) and (c), State law to the extent that State 
     law prevents the application of any provisions of law 
     established by or under this title. The provisions governing 
     health care lawsuits set forth in this title supersede 
     chapter 171 of title 28, United States Code, to the extent 
     that such chapter--
       (1) provides for a greater amount of damages or contingent 
     fees, a longer period in which a health care lawsuit may be 
     commenced, or a reduced applicability or scope of periodic 
     payment of future damages, than provided in this title; or
       (2) prohibits the introduction of evidence regarding 
     collateral source benefits, or mandates or permits 
     subrogation or a lien on collateral source benefits.
       (b) Protection of States' Rights and Other Laws.--(1) Any 
     issue that is not governed by any provision of law 
     established by or under this title (including State standards 
     of negligence) shall be governed by otherwise applicable 
     State or Federal law.
       (2) This title shall not preempt or supersede any State or 
     Federal law that imposes greater procedural or substantive 
     protections for health care providers and health care 
     organizations from liability, loss, or damages than those 
     provided by this title or create a cause of action.
       (c) State Flexibility.--No provision of this title shall be 
     construed to preempt--
       (1) any State law (whether effective before, on, or after 
     the date of the enactment of this Act) that specifies a 
     particular monetary amount of compensatory or punitive 
     damages (or the total amount of damages) that may be awarded 
     in a health care lawsuit, regardless of whether such monetary 
     amount is greater or lesser than is provided for under this 
     title, notwithstanding section 302(a); or
       (2) any defense available to a party in a health care 
     lawsuit under any other provision of State or Federal law.

     SEC. 310. APPLICABILITY; EFFECTIVE DATE.

       This title shall apply to any health care lawsuit brought 
     in a Federal or State court, or subject to an alternative 
     dispute resolution system, that is initiated on or after the 
     date of the enactment of this Act, except that any health 
     care lawsuit arising from an injury occurring prior to the 
     date of the enactment of this Act shall be governed by the 
     applicable statute of limitations provisions in effect at the 
     time the injury occurred.

         DIVISION D--PROTECTING THE DOCTOR-PATIENT RELATIONSHIP

     SEC. 401. RULE OF CONSTRUCTION.

       Nothing in this Act shall be construed to interfere with 
     the doctor-patient relationship or the practice of medicine.

[[Page 27552]]



     SEC. 402. REPEAL OF FEDERAL COORDINATING COUNCIL FOR 
                   COMPARATIVE EFFECTIVENESS RESEARCH.

       Effective on the date of the enactment of this Act, section 
     804 of the American Recovery and Reinvestment Act of 2009 is 
     repealed.

      DIVISION E--INCENTIVIZING WELLNESS AND QUALITY IMPROVEMENTS

     SEC. 501. INCENTIVES FOR PREVENTION AND WELLNESS PROGRAMS.

       (a) Employee Retirement Income Security Act of 1974 
     Limitation on Exception for Wellness Programs Under HIPAA 
     Discrimination Rules.--
       (1) In general.--Section 702(b)(2) of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 1182(b)(2)) 
     is amended by adding after and below subparagraph (B) the 
     following:

     ``In applying subparagraph (B), a group health plan (or a 
     health insurance issuer with respect to health insurance 
     coverage) may vary premiums and cost-sharing by up to 50 
     percent of the value of the benefits under the plan (or 
     coverage) based on participation in a standards-based 
     wellness program.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to plan years beginning more than 1 year after 
     the date of the enactment of this Act.
       (b) Conforming Amendments to PHSA.--
       (1) Group market rules.--
       (A) In general.--Section 2702(b)(2) of the Public Health 
     Service Act (42 U.S.C. 300gg-1(b)(2)) is amended by adding 
     after and below subparagraph (B) the following:

     ``In applying subparagraph (B), a group health plan (or a 
     health insurance issuer with respect to health insurance 
     coverage) may vary premiums and cost-sharing by up to 50 
     percent of the value of the benefits under the plan (or 
     coverage) based on participation in a standards-based 
     wellness program.''.
       (B) Effective date.--The amendment made by subparagraph (A) 
     shall apply to plan years beginning more than 1 year after 
     the date of the enactment of this Act.
       (2) Individual market rules relating to guaranteed 
     availability.--
       (A) In general.--Section 2741(f) of the Public Health 
     Service Act (42 U.S.C. 300gg-1(b)(2)) is amended by adding 
     after and below paragraph (1) the following:

     ``In applying paragraph (2), a health insurance issuer may 
     vary premiums and cost-sharing under health insurance 
     coverage by up to 50 percent of the value of the benefits 
     under the coverage based on participation in a standards-
     based wellness program.''.
       (B) Effective date.--The amendment made by paragraph (1) 
     shall apply to health insurance coverage offered or renewed 
     on and after the date that is 1 year after the date of the 
     enactment of this Act.
       (c) Conforming Amendments to IRC.--
       (1) In general.--Section 9802(b)(2) of the Internal Revenue 
     Code of 1986 is amended by adding after and below 
     subparagraph (B) the following:

     ``In applying subparagraph (B), a group health plan (or a 
     health insurance issuer with respect to health insurance 
     coverage) may vary premiums and cost-sharing by up to 50 
     percent of the value of the benefits under the plan (or 
     coverage) based on participation in a standards-based 
     wellness program.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to plan years beginning more than 1 year after 
     the date of the enactment of this Act.

                    DIVISION F--PROTECTING TAXPAYERS

     SEC. 601. PROVIDE FULL FUNDING TO HHS OIG AND HCFAC.

       (a) HCFAC Funding.-- Section 1817(k)(3)(A) of the Social 
     Security Act (42 U.S.C. 1395i(k)(3)(A)) is amended--
       (1) in clause (i)--
       (A) in subclause (IV), by striking ``2009, and 2010'' and 
     inserting ``and 2009''; and
       (B) by amending subclause (V) to read as follows:

       ``(V) for each fiscal year after fiscal year 2009, 
     $300,000,000.''; and

       (2) in clause (ii)--
       (A) in subclause (IX), by striking ``2009, and 2010'' and 
     inserting ``and 2009''; and
       (B) in subclause (X), by striking ``2010'' and inserting 
     ``2009'' and by inserting before the period at the end the 
     following: ``, plus the amount by which the amount made 
     available under clause (i)(V) for fiscal year 2010 exceeds 
     the amount made available under clause (i)(IV) for 2009''.
       (b) OIG Funding.--There are authorized to be appropriated 
     for each of fiscal years 2010 through 2019 $100,000,000 for 
     the Office of the Inspector General of the Department of 
     Health and Human Services for fraud prevention activities 
     under the Medicare and Medicaid programs.

     SEC. 602. PROHIBITING TAXPAYER FUNDED ABORTIONS AND 
                   CONSCIENCE PROTECTIONS.

       Title 1 of the United States Code is amended by adding at 
     the end the following new chapter:

   ``CHAPTER 4--PROHIBITING TAXPAYER FUNDED ABORTIONS AND CONSCIENCE 
                              PROTECTIONS

     ``SEC. 301. PROHIBITION ON FUNDING FOR ABORTIONS.

       ``No funds authorized or appropriated by federal law, and 
     none of the funds in any trust fund to which funds are 
     authorized or appropriated by federal law, shall be expended 
     for any abortion.

     ``SEC. 302. PROHIBITION ON FUNDING FOR HEALTH BENEFITS PLANS 
                   THAT COVER ABORTION.

       ``None of the funds authorized or appropriated by federal 
     law, and none of the funds in any trust fund to which funds 
     are authorized or appropriated by federal law, shall be 
     expended for a health benefits plan that includes coverage of 
     abortion.

     ``SEC. 303. TREATMENT OF ABORTIONS RELATED TO RAPE, INCEST, 
                   OR PRESERVING THE LIFE OF THE MOTHER.

       ``The limitations established in sections 301 and 302 shall 
     not apply to an abortion--
       ``(1) if the pregnancy is the result of an act of rape or 
     incest; or
       ``(2) in the case where a woman suffers from a physical 
     disorder, physical injury, or physical illness that would, as 
     certified by a physician, place the woman in danger of death 
     unless an abortion is performed, including a life-endangering 
     physical condition caused by or arising from the pregnancy 
     itself.

     ``SEC. 304. CONSTRUCTION RELATING TO SUPPLEMENTAL COVERAGE.

       ``Nothing in this chapter shall be construed as prohibiting 
     any individual, entity, or State or locality from purchasing 
     separate supplemental abortion plan or coverage that includes 
     abortion so long as such plan or coverage is paid for 
     entirely using only funds not authorized or appropriated by 
     federal law and such plan or coverage shall not be purchased 
     using matching funds required for a federally subsidized 
     program, including a State's or locality's contribution of 
     Medicaid matching funds.

     ``SEC. 305. CONSTRUCTION RELATING TO THE USE OF NON-FEDERAL 
                   FUNDS FOR HEALTH COVERAGE.

       ``Nothing in this chapter shall be construed as restricting 
     the ability of any managed care provider or other 
     organization from offering abortion coverage or the ability 
     of a State to contract separately with such a provider or 
     organization for such coverage with funds not authorized or 
     appropriated by federal law and such plan or coverage shall 
     not be purchased using matching funds required for a 
     federally subsidized program, including a State's or 
     locality's contribution of Medicaid matching funds.

     ``SEC. 306. NO GOVERNMENT DISCRIMINATION AGAINST CERTAIN 
                   HEALTH CARE ENTITIES.

       ``(a) In General.--No funds authorized or appropriated by 
     federal law may be made available to a Federal agency or 
     program, or to a State or local government, if such agency, 
     program, or government subjects any institutional or 
     individual health care entity to discrimination on the basis 
     that the health care entity does not provide, pay for, 
     provide coverage of, or refer for abortions.
       ``(b) Health Care Entity Defined.--For purposes of this 
     section, the term `health care entity' includes an individual 
     physician or other health care professional, a hospital, a 
     provider-sponsored organization, a health maintenance 
     organization, a health insurance plan, or any other kind of 
     health care facility, organization, or plan.''.

     SEC. 603. IMPROVED ENFORCEMENT OF THE MEDICARE AND MEDICAID 
                   SECONDARY PAYER PROVISIONS.

       (a) Medicare.--
       (1) In general.--The Secretary, in coordination with the 
     Inspector General of the Department of Health and Human 
     Services, shall provide through the Coordination of Benefits 
     Contractor for the identification of instances where the 
     Medicare program should be, but is not, acting as a secondary 
     payer to an individual's private health benefits coverage 
     under section 1862(b) of the Social Security Act (42 U.S.C. 
     1395y(b)).
       (2) Updating procedures.--The Secretary shall update 
     procedures for identifying and resolving credit balance 
     situations which occur under the Medicare program when 
     payment under such title and from other health benefit plans 
     exceed the providers' charges or the allowed amount.
       (3) Report on improved enforcement.--Not later than 1 year 
     after the date of the enactment of this Act, the Secretary 
     shall submit a report to Congress on progress made in 
     improved enforcement of the Medicare secondary payer 
     provisions, including recoupment of credit balances.
       (b) Medicaid.--Section 1903 of the Social Security Act (42 
     U.S.C. 1396b) is amended by adding at the end the following 
     new subsection:
       ``(aa) Enforcement of Payer of Last Resort Provisions.--
       ``(1) Submission of state plan amendment.--Each State shall 
     submit, not later than 1 year after the date of the enactment 
     of this subsection, a State plan amendment that details how 
     the State will become fully compliant with the requirements 
     of section 1902(a)(25).
       ``(2) Bonus for compliance.--If a State submits a timely 
     State plan amendment under paragraph (1) that the Secretary 
     determines provides for full compliance of the State with the 
     requirements of section 1902(a)(25), the Secretary shall 
     provide for an additional payment to the State of $1,000,000. 
     If a State certifies, to the Secretary's satisfaction, that 
     it is already fully compliant

[[Page 27553]]

     with such requirements, such amount shall be increased to 
     $2,000,000.
       ``(3) Reduction for noncompliance.--If a State does not 
     submit such an amendment, the Secretary shall reduce the 
     Federal medical assistance percentage otherwise applicable 
     under this title by 1 percentage point until the State 
     submits such an amendment.
       ``(4) Ongoing reduction.--If at any time the Secretary 
     determines that a State is not in compliance with section 
     1902(a)(25), regardless of the status of the State's 
     submission of a State plan amendment under this subsection or 
     previous determinations of compliance such requirements, the 
     Secretary shall reduce the Federal medical assistance 
     percentage otherwise applicable under this title for the 
     State by 1 percentage point during the period of non-
     compliance as determined by the Secretary.''.

     SEC. 604. STRENGTHEN MEDICARE PROVIDER ENROLLMENT STANDARDS 
                   AND SAFEGUARDS.

       (a) Protecting Against the Fraudulent Use of Medicare 
     Provider Numbers.--Subject to subsection (c)(2)--
       (1) Screening new providers.--As a condition of a provider 
     of services or a supplier, including durable medical 
     equipment suppliers and home health agencies, applying for 
     the first time for a provider number under the Medicare 
     program and before granting billing privileges under such 
     title, the Secretary shall screen the provider or supplier 
     for a criminal background or other financial or operational 
     irregularities through fingerprinting, licensure checks, 
     site-visits, other database checks.
       (2) Application fees.--The Secretary shall impose an 
     application charge on such a provider or supplier in order to 
     cover the Secretary's costs in performing the screening 
     required under paragraph (1) and that is revenue neutral to 
     the Federal government.
       (3) Provisional approval.--During an initial, provisional 
     period (specified by the Secretary) In which such a provider 
     or supplier has been issued such a number, the Secretary 
     shall provide enhanced oversight of the activities of such 
     provider or supplier under the Medicare program, such as 
     through prepayment review and payment limitations.
       (4) Penalties for false statements.--In the case of a 
     provider or supplier that makes a false statement in an 
     application for such a number, the Secretary may exclude the 
     provider or supplier from participation under the Medicare 
     program, or may impose a civil money penalty (in the amount 
     described in section 1128A(a)(4) of the Social Security Act), 
     in the same manner as the Secretary may impose such an 
     exclusion or penalty under sections 1128 and 1128A, 
     respectively, of such Act in the case of knowing presentation 
     of a false claim described in section 1128A(a)(1)(A) of such 
     Act.
       (5) Disclosure requirements.--With respect to approval of 
     such an application, the Secretary--
       (A) shall require applicants to disclose previous 
     affiliation with enrolled entities that have uncollected debt 
     related to the Medicare or Medicaid programs;
       (B) may deny approval if the Secretary determines that 
     these affiliations pose undue risk to the Medicare or 
     Medicaid program, subject to an appeals process for the 
     applicant as determined by the Secretary; and
       (C) may implement enhanced safeguards (such as surety 
     bonds).
       (b) Moratoria.--The Secretary may impose moratoria on 
     approval of provider and supplier numbers under the Medicare 
     program for new providers of services and suppliers as 
     determined necessary to prevent or combat fraud a period of 
     delay for any one applicant cannot exceed 30 days unless 
     cause is shown by the Secretary.
       (c) Funding.--
       (1) In general.--There are authorized to be appropriated to 
     carry out this section such sums as may be necessary.
       (2) Condition.--The provisions of paragraphs (1) and (2) of 
     subsection (a) shall not apply unless and until funds are 
     appropriated to carry out such provisions.

     SEC. 605. TRACKING BANNED PROVIDERS ACROSS STATE LINES.

        (a) Greater Coordination.--The Secretary of Health and 
     Human Services shall provide for increased coordination 
     between the Administrator of the Centers for Medicare & 
     Medicaid Services (in this section referred to as ``CMS'') 
     and its regional offices to ensure that providers of services 
     and suppliers that have operated in one State and are 
     excluded from participation in the Medicare program are 
     unable to begin operation and participation in the Medicare 
     program in another State.
       (b) Improved Information Systems.--
       (1) In general.--The Secretary shall improve information 
     systems to allow greater integration between databases under 
     the Medicare program so that--
       (A) medicare administrative contractors, fiscal 
     intermediaries, and carriers have immediate access to 
     information identifying providers and suppliers excluded from 
     participation in the Medicare and Medicaid program and other 
     Federal health care programs; and
       (B) such information can be shared across Federal health 
     care programs and agencies, including between the Departments 
     of Health and Human Services, the Social Security 
     Administration, the Department of Veterans Affairs, the 
     Department of Defense, the Department of Justice, and the 
     Office of Personnel Management.
       (c) Medicare/Medicaid ``One PI'' Database.--The Secretary 
     shall implement a database that includes claims and payment 
     data for all components of the Medicare program and the 
     Medicaid program.
       (d) Authorizing Expanded Data Matching.--Notwithstanding 
     any provision of the Computer Matching and Privacy Protection 
     Act of 1988 to the contrary--
       (1) the Secretary and the Inspector General in the 
     Department of Health and Human Services may perform data 
     matching of data from the Medicare program with data from the 
     Medicaid program; and
       (2) the Commissioner of Social Security and the Secretary 
     may perform data matching of data of the Social Security 
     Administration with data from the Medicare and Medicaid 
     programs.
       (e) Consolidation of Data Bases.--The Secretary shall 
     consolidate and expand into a centralized data base for 
     individuals and entities that have been excluded from Federal 
     health care programs the Healthcare Integrity and Protection 
     Data Bank, the National Practitioner Data Bank, the List of 
     Excluded Individuals/Entities, and a national patient abuse/
     neglect registry.
       (f) Comprehensive Provider Database.--
       (1) Establishment.--The Secretary shall establish a 
     comprehensive database that includes information on providers 
     of services, suppliers, and related entities participating in 
     the Medicare program, the Medicaid program, or both. Such 
     database shall include, information on ownership and business 
     relationships, history of adverse actions, results of site 
     visits or other monitoring by any program.
       (2) Use.--Prior to issuing a provider or supplier number 
     for an entity under the Medicare program, the Secretary shall 
     obtain information on the entity from such database to assure 
     the entity qualifies for the issuance of such a number.
       (g) Comprehensive Sanctions Database.--The Secretary shall 
     establish a comprehensive sanctions database on sanctions 
     imposed on providers of services, suppliers, and related 
     entities. Such database shall be overseen by the Inspector 
     General of the Department of Health and Human Services and 
     shall be linked to related databases maintained by State 
     licensure boards and by Federal or State law enforcement 
     agencies.
       (h) Access to Claims and Payment Databases.--The Secretary 
     shall ensure that the Inspector General of the Department of 
     Health and Human Services and Federal law enforcement 
     agencies have direct access to all claims and payment 
     databases of the Secretary under the Medicare or Medicaid 
     programs.
       (i) Civil Money Penalties for Submission of Erroneous 
     Information.--In the case of a provider of services, 
     supplier, or other entity that submits erroneous information 
     that serves as a basis for payment of any entity under the 
     Medicare or Medicaid program, the Secretary may impose a 
     civil money penalty of not to exceed $50,000 for each such 
     erroneous submission. A civil money penalty under this 
     subsection shall be imposed and collected in the same manner 
     as a civil money penalty under subsection (a) of section 
     1128A of the Social Security Act is imposed and collected 
     under that section.

         DIVISION G--PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS

     SEC. 701. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL 
                   PRODUCTS.

       (a) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--Section 351 of the Public Health Service 
     Act (42 U.S.C. 262) is amended--
       (1) in subsection (a)(1)(A), by inserting ``under this 
     subsection or subsection (k)'' after ``biologics license''; 
     and
       (2) by adding at the end the following:
       ``(k) Licensure of Biological Products as Biosimilar or 
     Interchangeable.--
       ``(1) In general.--Any person may submit an application for 
     licensure of a biological product under this subsection.
       ``(2) Content.--
       ``(A) In general.--
       ``(i) Required information.--An application submitted under 
     this subsection shall include information demonstrating 
     that--

       ``(I) the biological product is biosimilar to a reference 
     product based upon data derived from--

       ``(aa) analytical studies that demonstrate that the 
     biological product is highly similar to the reference product 
     notwithstanding minor differences in clinically inactive 
     components;
       ``(bb) animal studies (including the assessment of 
     toxicity); and
       ``(cc) a clinical study or studies (including the 
     assessment of immunogenicity and pharmacokinetics or 
     pharmacodynamics) that are sufficient to demonstrate safety, 
     purity, and potency in 1 or more appropriate conditions of 
     use for which the reference product is licensed and intended 
     to be used and for which licensure is sought for the 
     biological product;

       ``(II) the biological product and reference product utilize 
     the same mechanism or mechanisms of action for the condition 
     or

[[Page 27554]]

     conditions of use prescribed, recommended, or suggested in 
     the proposed labeling, but only to the extent the mechanism 
     or mechanisms of action are known for the reference product;
       ``(III) the condition or conditions of use prescribed, 
     recommended, or suggested in the labeling proposed for the 
     biological product have been previously approved for the 
     reference product;
       ``(IV) the route of administration, the dosage form, and 
     the strength of the biological product are the same as those 
     of the reference product; and
       ``(V) the facility in which the biological product is 
     manufactured, processed, packed, or held meets standards 
     designed to assure that the biological product continues to 
     be safe, pure, and potent.

       ``(ii) Determination by secretary.--The Secretary may 
     determine, in the Secretary's discretion, that an element 
     described in clause (i)(I) is unnecessary in an application 
     submitted under this subsection.
       ``(iii) Additional information.--An application submitted 
     under this subsection--

       ``(I) shall include publicly available information 
     regarding the Secretary's previous determination that the 
     reference product is safe, pure, and potent; and
       ``(II) may include any additional information in support of 
     the application, including publicly available information 
     with respect to the reference product or another biological 
     product.

       ``(B) Interchangeability.--An application (or a supplement 
     to an application) submitted under this subsection may 
     include information demonstrating that the biological product 
     meets the standards described in paragraph (4).
       ``(3) Evaluation by secretary.--Upon review of an 
     application (or a supplement to an application) submitted 
     under this subsection, the Secretary shall license the 
     biological product under this subsection if--
       ``(A) the Secretary determines that the information 
     submitted in the application (or the supplement) is 
     sufficient to show that the biological product--
       ``(i) is biosimilar to the reference product; or
       ``(ii) meets the standards described in paragraph (4), and 
     therefore is interchangeable with the reference product; and
       ``(B) the applicant (or other appropriate person) consents 
     to the inspection of the facility that is the subject of the 
     application, in accordance with subsection (c).
       ``(4) Safety standards for determining 
     interchangeability.--Upon review of an application submitted 
     under this subsection or any supplement to such application, 
     the Secretary shall determine the biological product to be 
     interchangeable with the reference product if the Secretary 
     determines that the information submitted in the application 
     (or a supplement to such application) is sufficient to show 
     that--
       ``(A) the biological product--
       ``(i) is biosimilar to the reference product; and
       ``(ii) can be expected to produce the same clinical result 
     as the reference product in any given patient; and
       ``(B) for a biological product that is administered more 
     than once to an individual, the risk in terms of safety or 
     diminished efficacy of alternating or switching between use 
     of the biological product and the reference product is not 
     greater than the risk of using the reference product without 
     such alternation or switch.
       ``(5) General rules.--
       ``(A) One reference product per application.--A biological 
     product, in an application submitted under this subsection, 
     may not be evaluated against more than 1 reference product.
       ``(B) Review.--An application submitted under this 
     subsection shall be reviewed by the division within the Food 
     and Drug Administration that is responsible for the review 
     and approval of the application under which the reference 
     product is licensed.
       ``(C) Risk evaluation and mitigation strategies.--The 
     authority of the Secretary with respect to risk evaluation 
     and mitigation strategies under the Federal Food, Drug, and 
     Cosmetic Act shall apply to biological products licensed 
     under this subsection in the same manner as such authority 
     applies to biological products licensed under subsection (a).
       ``(D) Restrictions on biological products containing 
     dangerous ingredients.--If information in an application 
     submitted under this subsection, in a supplement to such an 
     application, or otherwise available to the Secretary shows 
     that a biological product--
       ``(i) is, bears, or contains a select agent or toxin listed 
     in section 73.3 or 73.4 of title 42, section 121.3 or 121.4 
     of title 9, or section 331.3 of title 7, Code of Federal 
     Regulations (or any successor regulations); or
       ``(ii) is, bears, or contains a controlled substance in 
     schedule I or II of section 202 of the Controlled Substances 
     Act, as listed in part 1308 of title 21, Code of Federal 
     Regulations (or any successor regulations);

     the Secretary shall not license the biological product under 
     this subsection unless the Secretary determines, after 
     consultation with appropriate national security and drug 
     enforcement agencies, that there would be no increased risk 
     to the security or health of the public from licensing such 
     biological product under this subsection.
       ``(6) Exclusivity for first interchangeable biological 
     product.--Upon review of an application submitted under this 
     subsection relying on the same reference product for which a 
     prior biological product has received a determination of 
     interchangeability for any condition of use, the Secretary 
     shall not make a determination under paragraph (4) that the 
     second or subsequent biological product is interchangeable 
     for any condition of use until the earlier of--
       ``(A) 1 year after the first commercial marketing of the 
     first interchangeable biosimilar biological product to be 
     approved as interchangeable for that reference product;
       ``(B) 18 months after--
       ``(i) a final court decision on all patents in suit in an 
     action instituted under subsection (l)(5) against the 
     applicant that submitted the application for the first 
     approved interchangeable biosimilar biological product; or
       ``(ii) the dismissal with or without prejudice of an action 
     instituted under subsection (l)(5) against the applicant that 
     submitted the application for the first approved 
     interchangeable biosimilar biological product; or
       ``(C)(i) 42 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has been sued under 
     subsection (l)(5) and such litigation is still ongoing within 
     such 42-month period; or
       ``(ii) 18 months after approval of the first 
     interchangeable biosimilar biological product if the 
     applicant that submitted such application has not been sued 
     under subsection (l)(5).

     For purposes of this paragraph, the term `final court 
     decision' means a final decision of a court from which no 
     appeal (other than a petition to the United States Supreme 
     Court for a writ of certiorari) has been or can be taken.
       ``(7) Exclusivity for reference product.--
       ``(A) Effective date of biosimilar application approval.--
     Approval of an application under this subsection may not be 
     made effective by the Secretary until the date that is 12 
     years after the date on which the reference product was first 
     licensed under subsection (a).
       ``(B) Filing period.--An application under this subsection 
     may not be submitted to the Secretary until the date that is 
     4 years after the date on which the reference product was 
     first licensed under subsection (a).
       ``(C) First licensure.--Subparagraphs (A) and (B) shall not 
     apply to a license for or approval of--
       ``(i) a supplement for the biological product that is the 
     reference product; or
       ``(ii) a subsequent application filed by the same sponsor 
     or manufacturer of the biological product that is the 
     reference product (or a licensor, predecessor in interest, or 
     other related entity) for--

       ``(I) a change (not including a modification to the 
     structure of the biological product) that results in a new 
     indication, route of administration, dosing schedule, dosage 
     form, delivery system, delivery device, or strength; or
       ``(II) a modification to the structure of the biological 
     product that does not result in a change in safety, purity, 
     or potency.

       ``(8) Pediatric studies.--
       ``(A) Exclusivity.--If, before or after licensure of the 
     reference product under subsection (a) of this section, the 
     Secretary determines that information relating to the use of 
     such product in the pediatric population may produce health 
     benefits in that population, the Secretary makes a written 
     request for pediatric studies (which shall include a 
     timeframe for completing such studies), the applicant or 
     holder of the approved application agrees to the request, 
     such studies are completed using appropriate formulations for 
     each age group for which the study is requested within any 
     such timeframe, and the reports thereof are submitted and 
     accepted in accordance with section 505A(d)(3) of the Federal 
     Food, Drug, and Cosmetic Act the period referred to in 
     paragraph (7)(A) of this subsection is deemed to be 12 years 
     and 6 months rather than 12 years.
       ``(B) Exception.--The Secretary shall not extend the period 
     referred to in subparagraph (A) of this paragraph if the 
     determination under section 505A(d)(3) of the Federal Food, 
     Drug, and Cosmetic Act is made later than 9 months prior to 
     the expiration of such period.
       ``(C) Application of certain provisions.--The provisions of 
     subsections (a), (d), (e), (f), (h), (j), (k), and (l) of 
     section 505A of the Federal Food, Drug, and Cosmetic Act 
     shall apply with respect to the extension of a period under 
     subparagraph (A) of this paragraph to the same extent and in 
     the same manner as such provisions apply with respect to the 
     extension of a period under subsection (b) or (c) of section 
     505A of the Federal Food, Drug, and Cosmetic Act.
       ``(9) Guidance documents.--
       ``(A) In general.--The Secretary may, after opportunity for 
     public comment, issue guidance in accordance, except as 
     provided in subparagraph (B)(i), with section 701(h) of the 
     Federal Food, Drug, and Cosmetic Act with respect to the 
     licensure of a biological product under this subsection. Any 
     such guidance may be general or specific.

[[Page 27555]]

       ``(B) Public comment.--
       ``(i) In general.--The Secretary shall provide the public 
     an opportunity to comment on any proposed guidance issued 
     under subparagraph (A) before issuing final guidance.
       ``(ii) Input regarding most valuable guidance.--The 
     Secretary shall establish a process through which the public 
     may provide the Secretary with input regarding priorities for 
     issuing guidance.
       ``(C) No requirement for application consideration.--The 
     issuance (or non-issuance) of guidance under subparagraph (A) 
     shall not preclude the review of, or action on, an 
     application submitted under this subsection.
       ``(D) Requirement for product class-specific guidance.--If 
     the Secretary issues product class-specific guidance under 
     subparagraph (A), such guidance shall include a description 
     of--
       ``(i) the criteria that the Secretary will use to determine 
     whether a biological product is highly similar to a reference 
     product in such product class; and
       ``(ii) the criteria, if available, that the Secretary will 
     use to determine whether a biological product meets the 
     standards described in paragraph (4).
       ``(E) Certain product classes.--
       ``(i) Guidance.--The Secretary may indicate in a guidance 
     document that the science and experience, as of the date of 
     such guidance, with respect to a product or product class 
     (not including any recombinant protein) does not allow 
     approval of an application for a license as provided under 
     this subsection for such product or product class.
       ``(ii) Modification or reversal.--The Secretary may issue a 
     subsequent guidance document under subparagraph (A) to modify 
     or reverse a guidance document under clause (i).
       ``(iii) No effect on ability to deny license.--Clause (i) 
     shall not be construed to require the Secretary to approve a 
     product with respect to which the Secretary has not indicated 
     in a guidance document that the science and experience, as 
     described in clause (i), does not allow approval of such an 
     application.
       ``(10) Naming.--The Secretary shall ensure that the 
     labeling and packaging of each biological product licensed 
     under this subsection bears a name that uniquely identifies 
     the biological product and distinguishes it from the 
     reference product and any other biological products licensed 
     under this subsection following evaluation against such 
     reference product.
       ``(l) Patent Notices; Relationship to Final Approval.--
       ``(1) Definitions.--For the purposes of this subsection, 
     the term--
       ``(A) `biosimilar product' means the biological product 
     that is the subject of the application under subsection (k);
       ``(B) `relevant patent' means a patent that--
       ``(i) expires after the date specified in subsection 
     (k)(7)(A) that applies to the reference product; and
       ``(ii) could reasonably be asserted against the applicant 
     due to the unauthorized making, use, sale, or offer for sale 
     within the United States, or the importation into the United 
     States of the biosimilar product, or materials used in the 
     manufacture of the biosimilar product, or due to a use of the 
     biosimilar product in a method of treatment that is indicated 
     in the application;
       ``(C) `reference product sponsor' means the holder of an 
     approved application or license for the reference product; 
     and
       ``(D) `interested third party' means a person other than 
     the reference product sponsor that owns a relevant patent, or 
     has the right to commence or participate in an action for 
     infringement of a relevant patent.
       ``(2) Handling of confidential information.--Any entity 
     receiving confidential information pursuant to this 
     subsection shall designate one or more individuals to receive 
     such information. Each individual so designated shall execute 
     an agreement in accordance with regulations promulgated by 
     the Secretary. The regulations shall require each such 
     individual to take reasonable steps to maintain the 
     confidentiality of information received pursuant to this 
     subsection and use the information solely for purposes 
     authorized by this subsection. The obligations imposed on an 
     individual who has received confidential information pursuant 
     to this subsection shall continue until the individual 
     returns or destroys the confidential information, a court 
     imposes a protective order that governs the use or handling 
     of the confidential information, or the party providing the 
     confidential information agrees to other terms or conditions 
     regarding the handling or use of the confidential 
     information.
       ``(3) Public notice by secretary.--Within 30 days of 
     acceptance by the Secretary of an application filed under 
     subsection (k), the Secretary shall publish a notice 
     identifying--
       ``(A) the reference product identified in the application; 
     and
       ``(B) the name and address of an agent designated by the 
     applicant to receive notices pursuant to paragraph (4)(B).
       ``(4) Exchanges concerning patents.--
       ``(A) Exchanges with reference product sponsor.--
       ``(i) Within 30 days of the date of acceptance of the 
     application by the Secretary, the applicant shall provide the 
     reference product sponsor with a copy of the application and 
     information concerning the biosimilar product and its 
     production. This information shall include a detailed 
     description of the biosimilar product, its method of 
     manufacture, and the materials used in the manufacture of the 
     product.
       ``(ii) Within 60 days of the date of receipt of the 
     information required to be provided under clause (i), the 
     reference product sponsor shall provide to the applicant a 
     list of relevant patents owned by the reference product 
     sponsor, or in respect of which the reference product sponsor 
     has the right to commence an action of infringement or 
     otherwise has an interest in the patent as such patent 
     concerns the biosimilar product.
       ``(iii) If the reference product sponsor is issued or 
     acquires an interest in a relevant patent after the date on 
     which the reference product sponsor provides the list 
     required by clause (ii) to the applicant, the reference 
     product sponsor shall identify that patent to the applicant 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(B) Exchanges with interested third parties.--
       ``(i) At any time after the date on which the Secretary 
     publishes a notice for an application under paragraph (3), 
     any interested third party may provide notice to the 
     designated agent of the applicant that the interested third 
     party owns or has rights under 1 or more patents that may be 
     relevant patents. The notice shall identify at least 1 patent 
     and shall designate an individual who has executed an 
     agreement in accordance with paragraph (2) to receive 
     confidential information from the applicant.
       ``(ii) Within 30 days of the date of receiving notice 
     pursuant to clause (i), the applicant shall send to the 
     individual designated by the interested third party the 
     information specified in subparagraph (A)(i), unless the 
     applicant and interested third party otherwise agree.
       ``(iii) Within 90 days of the date of receiving information 
     pursuant to clause (ii), the interested third party shall 
     provide to the applicant a list of relevant patents which the 
     interested third party owns, or in respect of which the 
     interested third party has the right to commence or 
     participate in an action for infringement.
       ``(iv) If the interested third party is issued or acquires 
     an interest in a relevant patent after the date on which the 
     interested third party provides the list required by clause 
     (iii), the interested third party shall identify that patent 
     within 30 days of the date of issue of the patent, or the 
     date of acquisition of the interest in the patent, as 
     applicable.
       ``(C) Identification of basis for infringement.--For any 
     patent identified under clause (ii) or (iii) of subparagraph 
     (A) or under clause (iii) or (iv) of subparagraph (B), the 
     reference product sponsor or the interested third party, as 
     applicable--
       ``(i) shall explain in writing why the sponsor or the 
     interested third party believes the relevant patent would be 
     infringed by the making, use, sale, or offer for sale within 
     the United States, or importation into the United States, of 
     the biosimilar product or by a use of the biosimilar product 
     in treatment that is indicated in the application;
       ``(ii) may specify whether the relevant patent is available 
     for licensing; and
       ``(iii) shall specify the number and date of expiration of 
     the relevant patent.
       ``(D) Certification by applicant concerning identified 
     relevant patents.--Not later than 45 days after the date on 
     which a patent is identified under clause (ii) or (iii) of 
     subparagraph (A) or under clause (iii) or (iv) of 
     subparagraph (B), the applicant shall send a written 
     statement regarding each identified patent to the party that 
     identified the patent. Such statement shall either--
       ``(i) state that the applicant will not commence marketing 
     of the biosimilar product and has requested the Secretary to 
     not grant final approval of the application before the date 
     of expiration of the noticed patent; or
       ``(ii) provide a detailed written explanation setting forth 
     the reasons why the applicant believes--

       ``(I) the making, use, sale, or offer for sale within the 
     United States, or the importation into the United States, of 
     the biosimilar product, or the use of the biosimilar product 
     in a treatment indicated in the application, would not 
     infringe the patent; or
       ``(II) the patent is invalid or unenforceable.

       ``(5) Action for infringement involving reference product 
     sponsor.--If an action for infringement concerning a relevant 
     patent identified by the reference product sponsor under 
     clause (ii) or (iii) of paragraph (4)(A), or by an interested 
     third party under clause (iii) or (iv) of paragraph (4)(B), 
     is brought within 60 days of the date of receipt of a 
     statement under paragraph (4)(D)(ii), and the court in which 
     such action has been commenced determines the patent is 
     infringed prior to the date applicable under subsection 
     (k)(7)(A) or (k)(8), the Secretary shall make approval of the 
     application effective on the day after the date of expiration 
     of the patent that has been found to be infringed. If more 
     than one such patent is found to be infringed by the court, 
     the approval of the application shall be made effective on 
     the day after the date that the last such patent expires.

[[Page 27556]]

       ``(6) Notification of agreements.--
       ``(A) Requirements.--
       ``(i) Agreement between biosimilar product applicant and 
     reference product sponsor.--If a biosimilar product applicant 
     under subsection (k) and the reference product sponsor enter 
     into an agreement described in subparagraph (B), the 
     applicant and sponsor shall each file the agreement in 
     accordance with subparagraph (C).
       ``(ii) Agreement between biosimilar product applicants.--If 
     2 or more biosimilar product applicants submit an application 
     under subsection (k) for biosimilar products with the same 
     reference product and enter into an agreement described in 
     subparagraph (B), the applicants shall each file the 
     agreement in accordance with subparagraph (C).
       ``(B) Subject matter of agreement.--An agreement described 
     in this subparagraph--
       ``(i) is an agreement between the biosimilar product 
     applicant under subsection (k) and the reference product 
     sponsor or between 2 or more biosimilar product applicants 
     under subsection (k) regarding the manufacture, marketing, or 
     sale of--

       ``(I) the biosimilar product (or biosimilar products) for 
     which an application was submitted; or
       ``(II) the reference product;

       ``(ii) includes any agreement between the biosimilar 
     product applicant under subsection (k) and the reference 
     product sponsor or between 2 or more biosimilar product 
     applicants under subsection (k) that is contingent upon, 
     provides a contingent condition for, or otherwise relates to 
     an agreement described in clause (i); and
       ``(iii) excludes any agreement that solely concerns--

       ``(I) purchase orders for raw material supplies;
       ``(II) equipment and facility contracts;
       ``(III) employment or consulting contracts; or
       ``(IV) packaging and labeling contracts.

       ``(C) Filing.--
       ``(i) In general.--The text of an agreement required to be 
     filed by subparagraph (A) shall be filed with the Assistant 
     Attorney General and the Federal Trade Commission not later 
     than--

       ``(I) 10 business days after the date on which the 
     agreement is executed; and
       ``(II) prior to the date of the first commercial marketing 
     of, for agreements described in subparagraph (A)(i), the 
     biosimilar product that is the subject of the application or, 
     for agreements described in subparagraph (A)(ii), any 
     biosimilar product that is the subject of an application 
     described in such subparagraph.

       ``(ii) If agreement not reduced to text.--If an agreement 
     required to be filed by subparagraph (A) has not been reduced 
     to text, the persons required to file the agreement shall 
     each file written descriptions of the agreement that are 
     sufficient to disclose all the terms and conditions of the 
     agreement.
       ``(iii) Certification.--The chief executive officer or the 
     company official responsible for negotiating any agreement 
     required to be filed by subparagraph (A) shall include in any 
     filing under this paragraph a certification as follows: `I 
     declare under penalty of perjury that the following is true 
     and correct: The materials filed with the Federal Trade 
     Commission and the Department of Justice under section 
     351(l)(6) of the Public Health Service Act, with respect to 
     the agreement referenced in this certification: (1) represent 
     the complete, final, and exclusive agreement between the 
     parties; (2) include any ancillary agreements that are 
     contingent upon, provide a contingent condition for, or are 
     otherwise related to, the referenced agreement; and (3) 
     include written descriptions of any oral agreements, 
     representations, commitments, or promises between the parties 
     that are responsive to such section and have not been reduced 
     to writing.'.
       ``(D) Disclosure exemption.--Any information or documentary 
     material filed with the Assistant Attorney General or the 
     Federal Trade Commission pursuant to this paragraph shall be 
     exempt from disclosure under section 552 of title 5, United 
     States Code, and no such information or documentary material 
     may be made public, except as may be relevant to any 
     administrative or judicial action or proceeding. Nothing in 
     this subparagraph prevents disclosure of information or 
     documentary material to either body of the Congress or to any 
     duly authorized committee or subcommittee of the Congress.
       ``(E) Enforcement.--
       ``(i) Civil penalty.--Any person that violates a provision 
     of this paragraph shall be liable for a civil penalty of not 
     more than $11,000 for each day on which the violation occurs. 
     Such penalty may be recovered in a civil action--

       ``(I) brought by the United States; or
       ``(II) brought by the Federal Trade Commission in 
     accordance with the procedures established in section 
     16(a)(1) of the Federal Trade Commission Act.

       ``(ii) Compliance and equitable relief.--If any person 
     violates any provision of this paragraph, the United States 
     district court may order compliance, and may grant such other 
     equitable relief as the court in its discretion determines 
     necessary or appropriate, upon application of the Assistant 
     Attorney General or the Federal Trade Commission.
       ``(F) Rulemaking.--The Federal Trade Commission, with the 
     concurrence of the Assistant Attorney General and by rule in 
     accordance with section 553 of title 5, United States Code, 
     consistent with the purposes of this paragraph--
       ``(i) may define the terms used in this paragraph;
       ``(ii) may exempt classes of persons or agreements from the 
     requirements of this paragraph; and
       ``(iii) may prescribe such other rules as may be necessary 
     and appropriate to carry out the purposes of this paragraph.
       ``(G) Savings clause.--Any action taken by the Assistant 
     Attorney General or the Federal Trade Commission, or any 
     failure of the Assistant Attorney General or the Commission 
     to take action, under this paragraph shall not at any time 
     bar any proceeding or any action with respect to any 
     agreement between a biosimilar product applicant under 
     subsection (k) and the reference product sponsor, or any 
     agreement between biosimilar product applicants under 
     subsection (k), under any other provision of law, nor shall 
     any filing under this paragraph constitute or create a 
     presumption of any violation of any competition laws.''.
       (b) Definitions.--Section 351(i) of the Public Health 
     Service Act (42 U.S.C. 262(i)) is amended--
       (1) by striking ``In this section, the term `biological 
     product' means'' and inserting the following: ``In this 
     section:
       ``(1) The term `biological product' means'';
       (2) in paragraph (1), as so designated, by inserting 
     ``protein (except any chemically synthesized polypeptide),'' 
     after ``allergenic product,''; and
       (3) by adding at the end the following:
       ``(2) The term `biosimilar' or `biosimilarity', in 
     reference to a biological product that is the subject of an 
     application under subsection (k), means--
       ``(A) that the biological product is highly similar to the 
     reference product notwithstanding minor differences in 
     clinically inactive components; and
       ``(B) there are no clinically meaningful differences 
     between the biological product and the reference product in 
     terms of the safety, purity, and potency of the product.
       ``(3) The term `interchangeable' or `interchangeability', 
     in reference to a biological product that is shown to meet 
     the standards described in subsection (k)(4), means that the 
     biological product may be substituted for the reference 
     product without the intervention of the health care provider 
     who prescribed the reference product.
       ``(4) The term `reference product' means the single 
     biological product licensed under subsection (a) against 
     which a biological product is evaluated in an application 
     submitted under subsection (k).''.
       (c) Products Previously Approved Under Section 505.--
       (1) Requirement to follow section 351.--Except as provided 
     in paragraph (2), an application for a biological product 
     shall be submitted under section 351 of the Public Health 
     Service Act (42 U.S.C. 262) (as amended by this Act).
       (2) Exception.--An application for a biological product may 
     be submitted under section 505 of the Federal Food, Drug, and 
     Cosmetic Act (21 U.S.C. 355) if--
       (A) such biological product is in a product class for which 
     a biological product in such product class is the subject of 
     an application approved under such section 505 not later than 
     the date of enactment of this Act; and
       (B) such application--
       (i) has been submitted to the Secretary of Health and Human 
     Services (referred to in this Act as the ``Secretary'') 
     before the date of enactment of this Act; or
       (ii) is submitted to the Secretary not later than the date 
     that is 10 years after the date of enactment of this Act.
       (3) Limitation.--Notwithstanding paragraph (2), an 
     application for a biological product may not be submitted 
     under section 505 of the Federal Food, Drug, and Cosmetic Act 
     (21 U.S.C. 355) if there is another biological product 
     approved under subsection (a) of section 351 of the Public 
     Health Service Act that could be a reference product with 
     respect to such application (within the meaning of such 
     section 351) if such application were submitted under 
     subsection (k) of such section 351.
       (4) Deemed approved under section 351.--An approved 
     application for a biological product under section 505 of the 
     Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 
     deemed to be a license for the biological product under such 
     section 351 on the date that is 10 years after the date of 
     enactment of this Act.
       (5) Definitions.--For purposes of this subsection, the term 
     ``biological product'' has the meaning given such term under 
     section 351 of the Public Health Service Act (42 U.S.C. 262) 
     (as amended by this Act).

     SEC. 702. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

       Subparagraph (B) of section 735(1) of the Federal Food, 
     Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is amended by 
     inserting ``, including licensure of a biological product 
     under section 351(k) of such Act'' before the period at the 
     end.

     SEC. 703. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

       (a) Section 271(e)(2) of title 35, United States Code is 
     amended--

[[Page 27557]]

       (1) in subparagraph (A), by striking ``or'' after 
     ``patent,'';
       (2) in subparagraph (B), by adding ``or'' after the comma 
     at the end;
       (3) by inserting the following after subparagraph (B):
       ``(C) a statement under section 351(l)(4)(D)(ii) of the 
     Public Health Service Act,''; and
       (4) in the matter following subparagraph (C) (as added by 
     paragraph (3)), by inserting before the period the following: 
     ``, or if the statement described in subparagraph (C) is 
     provided in connection with an application to obtain a 
     license to engage in the commercial manufacture, use, or sale 
     of a biological product claimed in a patent or the use of 
     which is claimed in a patent before the expiration of such 
     patent''.
       (b) Section 271(e)(4) of title 35, United States Code, is 
     amended by striking ``in paragraph (2)'' in both places it 
     appears and inserting ``in paragraph (2)(A) or (2)(B)''.

  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
gentleman from Ohio (Mr. Boehner) and a Member opposed each will 
control 30 minutes.
  The Chair recognizes the gentleman from Ohio.

                              {time}  2015

  Mr. BOEHNER. Mr. Speaker, all of us know that our health care 
delivery system needs help. There could be broad bipartisan agreement 
on the kinds of steps that we need to take in order to lower the cost 
of health care in America and expand access. The bill before us, in my 
view, is a big government takeover of our health care system that will 
replace the current health care that Americans get.
  Republicans have offered better solutions all year on the major bills 
that have come to this floor. I think we had a much better solution on 
the stimulus bill that would have created twice the jobs at half the 
cost. I think our better solution on the budget clearly had less 
spending, less debt and lower deficits.
  I think our all-of-the-above American energy plan was a much better 
solution to the national energy tax, the so-called cap-and-trade bill, 
that was on this floor in June. I believe that what we have before us, 
as a Republican substitute, is a commonsense plan that takes steps 
towards reducing the cost of health insurance in America and expand 
access. Simple things, like allowing people to buy insurance across 
State lines, allowing groups of individuals or small businesses to 
group together for the purposes of buying health insurance like big 
businesses and unions can today. How about getting rid of junk lawsuits 
that drive up the cost of health care in America and the defensive 
medicine that doctors have to practice as a result.
  I think what we have before us and the bill that we are offering is a 
commonsense approach that does take major steps in the right direction 
to bring down the cost of health care and to expand access.
  I reserve the balance of my time.
  Mr. WAXMAN. Mr. Speaker, I seek to control the time in opposition, 
and I ask unanimous consent that the time for opposition speakers on 
the substitute amendment be divided such that the first 10 minutes is 
controlled by Chairman Miller of the Committee on Education and Labor; 
the second 10 minutes is controlled by Chairman Rangel of the Committee 
on Ways and Means; and the final 10 minutes is controlled by Chairman 
Waxman of the Committee on Energy and Commerce.
  The SPEAKER pro tempore. The gentleman from California (Mr. Waxman) 
is recognized to control the time in opposition.
  Without objection, that time will be so divided, subject to the 
Chair's discretion as to the order of recognition.
  There was no objection.
  The SPEAKER pro tempore. The Chair recognizes the gentleman from 
California (Mr. Miller).
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 2 minutes to 
the gentleman from New York (Mr. Tonko).
  Mr. TONKO. Mr. Speaker, I am here to speak in support of the 
Affordable Health Care for America Act, one of the most important 
pieces of legislation this body has considered since the passage of 
Medicare in 1965 and Social Security in 1935.
  Mr. Speaker, every Member of this body has been listening to her or 
his constituents, and they are saying that they are ready for health 
insurance reform. They need health insurance reform.
  We listened when seniors said they wanted better care from their 
doctors, and the doughnut hole eliminated. This bill does that. We 
listened when young adults told us they were having trouble finding 
insurance and wanted to stay on their parents' insurance until age 27. 
This bill does that. We listened when the uninsured told us 
heartbreaking stories about going without needed health care and asked 
us to give them affordable, quality health care insurance. This bill 
does that. We listened when the insured told us they were paying too 
much for insurance and they needed more protections for their health 
insurance. This bill does that.
  Our colleagues on the other side of the aisle have not listened. They 
are offering a substitute bill that would not accomplish any of the 
things our constituents have asked for. Instead, they are offering a 
bill that does not end the discrimination based on preexisting 
conditions; does not reduce the number of uninsured Americans; does not 
offer assistance to those struggling to afford health insurance; does 
not repeal the antitrust exemption for health insurers; and does not 
stop price gouging by insurance companies. Our bill does all these 
things and more.
  Mr. Speaker, the Affordable Health Care for America Act not only 
brings quality health care within reach of tens of millions of 
Americans, it enhances the care that those with insurance and Medicare 
already receive. This bill is as much about the insured as it is about 
the uninsured. It is a monumental bill. I urge defeat of the Republican 
substitute and, indeed, encourage passage of H.R. 3962.
  The SPEAKER pro tempore. Without objection, the gentleman from 
Michigan will control the time on the proponent's side.
  There was no objection.
  Mr. CAMP. Mr. Speaker, I yield myself 4 minutes.
  Mr. Speaker, the American people deserve and demand a commonsense 
approach to health care reform that, one, makes health care more 
affordable; two, that guarantees all Americans, regardless of 
preexisting condition, have access to affordable health care; and, 
three, does so without raising taxes, without increasing the deficit 
and without the Federal Government making health care decisions that 
should be made by patients and doctors.
  The Common Sense Health Care Reform and Affordability Act, the House 
Republican health care bill, does that. The plan offered today by the 
Speaker does not.
  Just some of the highlights of the Republicans' Common Sense Health 
Care Reform and Affordability Act include:
  Lowering health care premiums: The Republican plan will lower health 
care premiums for American families and small businesses, addressing 
Americans' number-one priority for health care reform.
  According to the Congressional Budget Office, the Republican health 
care reforms would reduce premiums by up to 3 percent for Americans who 
get insurance through a large business, up to 8 percent for Americans 
without employer-sponsored insurance, and up to 10 percent for those 
working for a small business. CBO has not made a claim that the 
Democrats' bill would lower premiums at all.
  What do these numbers mean? It means families who do not have health 
insurance in 2016 through their job could buy health insurance that is 
$5,000 less expensive than the cheapest plan the Democrats offer.
  The Republican plan guarantees access to affordable health care for 
those with preexisting conditions. Republicans create universal access 
programs that expand and reform high-risk pools and reinsurance 
programs to guarantee that all Americans, regardless of preexisting 
conditions or past illnesses, have access to affordable care, while 
lowering costs for all Americans.
  The Republican plan reduces the number of junk lawsuits, which saves 
taxpayers' money and lowers premiums, by enacting medical liability

[[Page 27558]]

reforms modeled after the successful State laws of California and 
Texas.
  The Republican plan prevents insurers from wrongly canceling a policy 
unless a person commits fraud.
  The Republican plan encourages Small Business Health Plans so these 
employers can pool together and offer health care at lower prices, just 
as large corporations and labor unions do today.
  The Republican plan encourages innovative programs by rewarding 
States that reduce premiums and the number of uninsured. In comparison, 
the Democrat bill adds a new unfunded mandate States cannot afford with 
their over $400 billion expansion of Medicaid.
  The Republican plan allows Americans to buy insurance across State 
lines and find the health care plan that best meets their needs at a 
cost they can afford.
  The Republican plan promotes prevention and wellness by more than 
doubling the financial incentives employers may reward employees who 
adopt healthier lifestyles.
  Republicans enhance health savings accounts by allowing Americans to 
use HSA funds to pay premiums for high deductible health insurance.
  And the Republican plan allows dependents to remain on their parents' 
policies up to the age of 25.
  The health insurance reforms in the Republican bill will 
significantly reduce health care premiums, insure millions of 
Americans, guarantee those with preexisting conditions have access to 
quality, affordable care.
  We do all of this without raising taxes, without spending $1 trillion 
we don't have, without cutting Medicare and without putting some new 
health czar in between doctors and patients, which is what the Democrat 
majority does in their government takeover bill.
  Clearly the bill offered by the Speaker is not what the American 
people want. Americans are clamoring for lower cost health care and 
that is what the Republican plan offers.
  I urge my colleagues to reject the Democrats' government takeover of 
health care and vote ``yes'' on the Republican substitute that will 
lower health care premiums.
  I reserve the balance of my time.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair would remind Members not to 
traffic the well when another Member is under recognition.
  Mr. GEORGE MILLER of California. Mr. Speaker, I yield 2\1/2\ minutes 
to the gentleman from Massachusetts (Mr. Tierney), a member of the 
committee.
  Mr. TIERNEY. I thank the gentleman.
  Since 1995, when our Republican colleagues held the majority in the 
House of Representatives, until 2007 when they relinquished that and 
the voters threw them out, they had done exactly nothing, nothing, with 
respect to the health care crisis in this country.
  Now they want to come in and they want to do something. They want to 
have you pay less for getting less. This is their great plan.
  The one thing they tried to do in 2003 would put pharmaceutical 
prescription drugs in Medicare which they did by giving seniors a so-
called doughnut hole they had to pay for and costing us $600 billion on 
our current debt.
  My friends, the only ones they made happy then were the 
pharmaceutical companies, and the only ones they want to make happy now 
are the private insurance companies. They want to try to kill reform. 
If they can't kill reform, they want to give them this gift of a 
Republican substitute.
  While they sat idle since 1995, family health insurance policies rose 
from 7 percent of median income to 17 percent. Sixty percent of 
families reporting bankruptcies did so in part because of health care 
costs. Forty-six million Americans went uninsured, 85 percent of those 
in working families.
  Small business premiums went up 129 percent. Twenty-eight million of 
our uninsured are small business owners, employees or their families. 
Small businesses are projected to lose $52.1 billion going forward in 
the next decade if we continue on the Republican path of do nothing.
  The question is, who is on our side? Who is on the side of the 
consumers, the individuals, the small businesses and the families, and 
that is the bill that the Democrats have put forward on this floor. It 
is affordable; it is health care for every American.
  If you compare the two bills, you will see the Congressional Budget 
Office says the Republicans may--may--save you from 0 to 3 percent on 
80 percent of the private premiums.
  The Democratic bill saves you 12 percent. The Democratic bill covers 
96 percent of Americans. The Republicans in 2019 will leave you exactly 
where you are today, covering only 83 percent of the people, leaving by 
that time 52 million uninsured.
  We will end the discrimination against people with preexisting 
conditions. They will study it.
  We will have an exchange for small businesses and employees so they 
get better prices comparable to what large companies have now been able 
to get. They will do nothing of the kind except let you shop for a 
place, but to get your insurance it might cost you less because you get 
less, because you will have a race to the bottom, where insurance 
companies will be able to avoid consumer protections of States and 
practice fraud almost indiscriminately. There will be no way of cutting 
it back. You pay less because you get less.
  Mr. CAMP. Mr. Speaker, I yield myself 15 seconds.
  When Republicans were in the majority, we passed a children's health 
initiative; a prescription drug plan for seniors; we put wellness into 
Medicare; we established portability so people could change jobs and 
keep their health care; and we established health savings accounts. Our 
record on health care is strong. What we need is this continuation of 
this step-by-step approach to comprehensive health care reform.
  I would now yield 5 minutes to the distinguished gentleman from 
Indiana (Mr. Pence).
  Mr. PENCE. Mr. Speaker, I rise in support of the Republican 
substitute.
  After months of overwhelming public opposition to a government 
takeover of health care, liberal Democrats here in Washington are 
choosing to ignore the clear voice of the American people, bringing 
forth a freight train of runaway Federal spending, bloated bureaucracy, 
mandates and higher taxes.
  And even a few courageous Democrats have been willing to speak out. 
In opposing the bill, the distinguished Democrat chairman of the Armed 
Services Committee, Ike Skelton, a man who knew President Truman, said 
that he, quote, had serious concerns for Missourians who have private 
insurance plans they like.
  And my Democrat colleague, Dan Boren of Oklahoma, said, and I quote, 
the worst thing we could do in a recession is raise taxes, and this 
bill does just that.

                              {time}  2030

  As these Democrat colleagues attest, if the Pelosi health care bill 
passes today, you probably will lose your health insurance, and you 
might just lose your job. The Pelosi health care plan targets us when 
we are most vulnerable. Illness, our own, or, more importantly, the 
illness of a parent, spouse or a child, has the capacity to suspend our 
priorities. What was important before the crisis grows dim in the harsh 
light of disease affecting a loved one. The result, little by little, 
in the midst of a family crisis we yield our freedoms and our resources 
to the ever-growing appetite of the Federal Government.
  But if liberal Democrats think this is what our Nation wants, they 
don't know the America that I know.
  Mike Schwaller is my cousin. He is an extraordinary young man. He has 
been struggling with cancer, but throughout has maintained his faith in 
Christ and his courage. He has been an inspiration to us all.
  Mike wrote me an email the other day, and he gave me permission to 
share it. As a cancer patient with limited treatment options, he is 
awaiting insurance approval for experimental treatment. He seems like 
just the kind of American that my Democrat colleagues keep telling us 
want government-run insurance. But they don't know Mike.

[[Page 27559]]

  As he wrote about his coverage recently, he said, If this was a 
government bureaucracy, I have no faith that it would be processed in a 
timely manner, and even then, if it would be approved. The idea of a 
public health care option, he wrote, as a chronic cancer patient scares 
the living hell out of me. I feel that at this moment in time you are 
fighting for me, and my life. Please, please, don't give up or give in.
  Michael, we won't.
  The truth is, this debate is not just about health care. It is about 
who we are as a nation. As President Reagan said, it is about ``whether 
we abandon the American revolution and confess that a little 
intellectual elite in a far distant capital can plan our lives better 
for us than we can plan them for ourselves.''
  You know, earlier today I greeted about 50 Hoosiers, mostly in 
wheelchairs, unit caps and uniforms, down at the World War II Memorial. 
These heroes were gathered for their first and maybe their only visit 
to that monument built in their honor.
  As I made my way back to the Capitol, I thought about those brave men 
and what sustained them in those days where the survival of democracy 
hung in the balance. I believe it must have been because they were 
fighting for a cause more important than their health or even their 
lives, and that cause was freedom.
  In the coming hours, we are going to take a vote of incalculable 
significance to the American people, and we will see what our so-called 
Blue Dog Democrat colleagues are made of. We will see whether Democrats 
who profess to believe in limited government will take a stand, or 
whether they will fold under the weight of the Democratic majority in 
the White House.
  Look, I know from personal experience, it is no easy thing to take on 
your President or your party on a major piece of legislation. But let 
me assure my colleagues, decent Americans all, if you will take this 
stand for freedom, for the right to live and work and care for a family 
without the unnecessary intrusion of the government, I believe with all 
my heart that you will know for the rest of your lives just what those 
men in wheelchairs have known every day since they came home, that when 
freedom hung in the balance, you did freedom's work, and the American 
people will never forget it.
  Mr. GEORGE MILLER of California. I yield 1\1/2\ minutes to the 
gentleman from Virginia (Mr. Scott), a member of the committee.
  Mr. SCOTT of Virginia. Mr. Speaker, all afternoon we have heard about 
the freedom to be uninsured. Seniors in my district do not want us to 
repeal government-run Medicare so that they can enjoy a freedom to be 
uninsured, and those without insurance now do not view themselves as 
enjoying some freedom. They want insurance.
  The Republican substitute responds to the comprehensive Affordable 
Healthcare for America Act with a bill that fails to reduce costs, 
fails to cover uninsured Americans, and it may study, but it does not 
help, those with preexisting conditions. It does, however, attack 
innocent victims of medical malpractice.
  One recent study showed that medical malpractice represents less than 
one-third of one percent of all health care costs, and yet the 
Republican substitute seeks to blame our broken health care insurance 
system on innocent victims of malpractice. For those victims, the bill 
limits the ability to hire a lawyer, complicates the lawsuit, shifts 
the cost of medical malpractice from the doctor to the victim's own 
private insurance, and, in some cases, causes the injured victims to 
lose the right to sue before they even know they have been injured.
  None of these unfair provisions were passed during previous attempts 
when the Republicans controlled the House, the Senate and the White 
House, and they should not be passed now.
  The substitute should be defeated.
  Mr. CAMP. Mr. Speaker, I yield 3 minutes to the distinguished 
gentleman from Michigan (Mr. McCotter).
  Mr. McCOTTER. I thank the gentleman.
  Mr. Speaker, as the health redistribution bill before us attempts to 
put its skid marks on history, it further proves Democrats are the 
party of the past. Their antiquated government-run takeover of 
Americans' health care is as ill-suited to our times as a leeching is 
to laser surgery.
  We do not live on a government-run globe. We live in a people-powered 
world, one belatedly awakening to America's revolutionary experiment in 
human freedom and self-government. Today, from the palms of our hands, 
we can traverse distant strands of Earth to access friends and goods. 
Why in the world would we put in the palm of a bureaucrat's hand our 
health care?
  Yet, this is precisely what the hoary voices of hidebound ideologues 
demand; namely, that our generation's innovation revolution and its 
unprecedented expansion of human empowerment be buried beneath big 
government.
  They are gravely mistaken. Amidst our constantly changing and 
challenging times during this age of globalization, our generation's 
innovation revolution is burying big government in the ash bin of 
history.
  Thus, the public and Republicans oppose the Democrat's fossilized 
model of a mammoth government-run takeover of Americans' health care. 
Instead, we embrace and harness our generation's innovation revolution 
to empower Americans as citizens and consumers and advance patient-
centered wellness.
  Our plan will increase the supply of health care to meet rising 
demand and reduce costs through such sensible, affordable, and helpful 
reforms as ending exclusions for preexisting conditions, reforming 
medical liability laws, expanding Health Savings Accounts, allowing 
small businesses to band together to provide coverage for employees, 
permitting health insurance sales across State lines, and incentivizing 
preventative health care and wellness.
  All this can be achieved without trillions of dollars in new 
spending, taxes, deficit and debt, and without big government 
controlling your health care decisions.
  Trapped in the past, there are those who ignore behind closed doors 
the opportunities of our age. If Democrats impose their government-run 
takeover of health care on the American people, the consequences will 
be higher costs, lower quality, fewer choices, and lost jobs during 
this painful recession.
  But for those with an abiding faith in our free Republic's people and 
their future, there is a better way--maximizing America's innovation 
revolution to advance patient-centered wellness in our people-powered 
world.
  Pray we do.
  Mr. GEORGE MILLER of California. I yield 2 minutes to the gentleman 
from New Jersey (Mr. Andrews), a member of the committee.
  Mr. ANDREWS. Mr. Speaker, when you can't win an argument on the 
facts, you resort to emotion. The minority can't win the argument with 
insured people because they preserve the right of insurance companies 
to discriminate on the basis of preexisting conditions.
  They can't win the argument with senior citizens because they ignore 
the doughnut hole that they created in 2003 in the Medicare part D.
  And they don't ignore the uninsured. I will give them some credit for 
that. There are going to be 50 million uninsured in 2010. They do 
change that. Their plan would make it 55 million uninsured 10 years 
from now.
  So they are standing on a motion, and we hear a Member say this: ``We 
cannot stand idly by now, as the Nation is urged to embark on an ill-
conceived adventure in government medicine, the end of which no one can 
see, and from which the patient is certain to be the ultimate 
sufferer.''
  But the Member wasn't a current Member, and the time wasn't now, and 
the issue wasn't this bill. The Member was Durward Hall, the time was 
1965, and the issue was Medicare.
  They were wrong then, they are wrong now, and their substitute is 
wrong. You should vote no.
  Mr. GEORGE MILLER of California. I yield myself 2 minutes.
  Mr. Speaker, if the Republicans' health care plan was a plan for a 
fire department, they would rush into a

[[Page 27560]]

burning building, and they would rush out and leave everybody behind. 
If their plan was an evacuation plan, it would be like Katrina. When 
they got all done evacuating people, they left them all behind.
  They say their plan is inexpensive. They say their plan saves 
somebody money. But 10 years from now there are as many uninsured as 
there are now.
  At the end of their watch, after 12 years of control of this 
Congress, 8 years of control of the White House at the same time, they 
left behind 37 million Americans without health insurance. That is what 
they left behind on their watch. Now they come forth with a plan for 
the future, and over the next decade they are going to leave behind 50 
million Americans.
  Want to buy it? Want to try it? Want to sell it? Come on, America. 
Buy this one. You are guaranteed to be left behind if you are left 
behind today.
  What a plan. Ha. God save us.
  Mr. CAMP. At this time I yield 3 minutes to the distinguished 
gentleman from Texas (Mr. Barton), the ranking member of the Energy and 
Commerce Committee.
  Mr. BARTON of Texas. Mr. Speaker, I asked to go after the 
distinguished chairman of the Education and Labor Committee because 
what we have here is a failure to communicate, or perhaps a difference 
in philosophy.
  The Democrats have decided that the bottom line is coverage. By 
golly, coverage no matter what. Whether you want to be covered or not, 
you are going to be. We are going to have an employer mandate. We are 
going to have an employee mandate and an individual mandate. We are 
going to have a premium mandate.
  We are going to have how you cover the insurance, a ``comparative 
research council,'' to dictate the practice of medicine. We are going 
to raise Medicaid to 150 percent of poverty, and automatically enroll 
every individual in this country who is unmarried, whether they want to 
be or not.
  We are going to tell every young American who has decided that they 
don't want to pay those premiums, they want to save up to get married 
or to buy a home, that, by golly, they are going to have to take 
insurance, and they are going to pay three to four times what they 
would under the current system because there is only a two-to-one 
ratio. So they are going to get their coverage, at a cost of $1.2 
trillion.
  Now, we have a different philosophy. We think you need to control 
costs, but we also agree that you have to provide access to the private 
insurance market if you can't get it today and you want it.
  Congressman Miller talks about the 40 to 50 million Americans that 
are not insured, and he is right. But of those 40 to 50 million, 15 to 
20 million are in this country illegally. Ten or 15 million are young 
Americans who don't want insurance.
  When you really boil it down, there are 5 to 10 million Americans who 
have a preexisting condition or work where insurance is not provided 
and they can't afford it.

                              {time}  2045

  Our plan covers them. It gives them the opportunity. That doesn't 
give them the money, but it gives them the opportunity. So we have a 
difference in a philosophy.
  We don't believe in mandates and make no apology about it, but we do 
believe in the individual opportunity. We believe in individual choice. 
We believe in the American system of free enterprise. We believe in 
lowered taxes, and we believe in a plan that's going to lower premiums 
an average of $5,000 per person per year for the next 10 years. That's 
what CBO says. That's not me. That's the CBO.
  So there is a choice. Bigger government, more mandates, more control, 
less freedom, or lower costs, more opportunity, more freedom, more 
choice. I vote for more freedom.
  Vote ``no'' on the Big Government plan. Vote ``yes'' on the 
individual opportunity plan.
  Mr. RANGEL. At this time, I yield 1 minute to the gentleman from 
California (Mr. Stark), the chairman of the Ways and Means Subcommittee 
on Health.
  I would like to take this time to thank him for the great work he's 
done over the years, not just for our committee, but for this Congress, 
and I would like to thank him publicly.
  Mr. STARK. I thank the chairman for yielding.
  Mr. Speaker, the Republican substitute is not a substitute on health 
reform. It substitutes gifts to the wealthy insurance companies for 
morality and dignity. Their bill spends $61 billion over the next 
decade, and what would the American public get for that investment? It 
would get 5 million more uninsured people than we have in America 
today. That's not a conservative solution. It's no solution at all.
  Our legislation expands coverage to 36 million more Americans, 
reforms the insurance market to end abusive practices, provides 
financial assistance to lower-income and middle-income families, 
creates a public health insurance option that will make health 
insurance companies compete on quality, provides security for our 
seniors, and protects our children's futures by not adding one dime to 
the deficit.
  A vote for the Republican substitute is nothing more than a vote for 
transferring money to wealthy insurance companies. Vote ``no'' on the 
Republican substitute and ``yes'' to provide affordable, quality health 
care for all Americans.
  Mr. CAMP. At this time, I yield 1 minute to the gentleman from South 
Carolina (Mr. Brown).
  Mr. BROWN of South Carolina. Mr. Speaker, I rise in strong support of 
the Republican amendment and true health care reform. Our plan makes 
the cost-saving changes so sorely needed in our health care system 
without forcing our children and grandchildren into unending debt.
  This amendment will allow insurance to be bought across State lines 
to drive down costs and allow small businesses to band together in 
order to negotiate fair and affordable coverage. Furthermore, this 
amendment improves quality, putting you and your doctor in charge of 
your care by removing the powers of insurance companies and trial 
lawyers.
  Finally, this amendment ensures that the taxpayer dollars my 
constituents in South Carolina's First Congressional District pay into 
the Federal Treasury never find their way into abortion clinics.
  Mr. Speaker, Republicans have a better plan. I urge all of my 
colleagues to support this amendment and urge them to vote ``no'' on 
final passage.
  Mr. RANGEL. Mr. Speaker, I yield 2 minutes to the gentleman from 
Washington, Dr. McDermott, who worked his whole career down here to 
improve the quality of health care for all Americans.
  Mr. McDERMOTT. Mr. Speaker, the Republican health plan and proposal 
has been in effect since 1995. A friend of mine came to New York, had 
some problems, got on the phone to call a doctor, and the first 
question that is always asked is what kind of insurance do you have. 
When he said he didn't have any, they said, Well, we can't take care of 
you unless you come to the office with $250 in cash. We'll see you if 
you do that. He said, I don't have that kind of money. They said, Then 
go to the emergency room. That's where 50 million people in this 
country are today. Go to the emergency room if you can't come with the 
cash to hand it to the doctor.
  My office phone today has been ringing off the hook with people 
demanding that we have health care now. The Republican alternative 
doesn't help anyone, except protects the insurance companies. The 
bankruptcy of this plan is pretty clear to everybody. Health analysts, 
the media, The New York Times, the CBO all agree that the Republican 
plan would leave 42 million people with nothing.
  Now, the Republican plan does nothing to help the seniors. It really 
isn't a plan. It's just a bunch of stuff they scraped up off the floor 
that they had laying around for 12 years and did nothing.
  Now, why don't they put forward a plan? Well, I will tell you. I've 
cracked the code. This plan they brought out

[[Page 27561]]

here, they either haven't read their own bill--because you couldn't 
keep a straight face and come out here and say it was a plan--or they 
would rather spend more time hating government than helping people. 
Remember what they did in New Orleans. That's what their attitude about 
government is. Don't make it work for the people. Just let people 
understand, You're on your own, folks. That's our plan. We believe in 
freedom; you're free to be on your own. But most people can't take care 
of their health care problems on their own. They're lucky if they can.
  Vote against this proposal, and vote for the bill.
  The phones in my office have been ringing off the hook because my 
constituents want secure quality affordable healthcare now. Meanwhile 
the Republicans have put forward an alternative that doesn't help 
anyone but protect insurance companies.
  The bankruptcy of the Republican plan is not just my opinion--
analysts, the media, and the Congressional Budget Office all agree the 
Republican plan will leave 42 million out in the cold. The Republican 
plan does nothing to help people with pre-existing conditions or to 
help seniors. The Republican plan is no plan.
  How could they have put forward a plan that doesn't solve any of the 
healthcare problems Americans face? Well, I may have cracked the code. 
Either they haven't read their own bill or they'd rather spend more 
time hating government than helping people.
  The Republican approach is just a continuation of the status quo 
while the Democratic plan covers 96% of Americans. My constituents have 
demanded action. The time is now.
  Mr. RANGEL. No one has worked harder on this bill than Congressman 
Lloyd Doggett from Texas, and it's my honor to now yield 2 minutes to 
the gentleman.
  Mr. DOGGETT. To help cover huge medical bills in Bastrop, Texas, they 
held a Main Street pancake supper, an auction at the American Legion. 
Well, essential health care shouldn't depend on the kindness of 
strangers or the goodness of neighbors and certainly not on the ``just 
say no'' of the Republican Party or the weak TEA parties brewed up by 
the insurance lobby.
  Now, belatedly, they offer a scheme as skimpy as a hospital gown. 
They do nothing to help seniors. Their proposal is inefficient, it's 
ineffective, and it's wasteful. Masquerading as reform, their bill 
authorizes insurers to continue denying coverage for preexisting health 
conditions, such as acne or a C-section. Republican obstructionism has 
itself become one giant preexisting condition to meaningful change.
  This is a typical old-time Republican medicine show. Do a little bit 
for 5 percent of the people. Do nothing for the other 95 percent of the 
uninsured, and leave the portion of American families who are uninsured 
the same tomorrow as today. The only thing they propose more of is more 
insurance policy loopholes.
  Freedom. They want the freedom to go broke after a medical emergency, 
the freedom to have more bankruptcies, medical bills--the number one 
cause of personal bankruptcy in America today. We cannot secure 
bipartisan support for health insurance reform tonight because they 
don't support any real solutions for the uninsured.
  Our Democratic plan is a lifesaver for 12 times as many Americans, 
and it's a dollar saver, responsibly reducing the national debt by $36 
billion more than this phony Republican scheme.
  Now is the time for a truly historic choice. The Republicans have 
chosen to side again with the big insurance monopolies. We choose to 
strengthen Medicare. We chose to stand up for the millions of 
struggling families who have been denied health care access for too 
long.
  Mr. RANGEL. Could I ask how much time I have remaining, Mr. Speaker?
  The SPEAKER pro tempore. The gentleman from New York has 5 minutes 
remaining.
  Mr. RANGEL. I yield 2 minutes of that time to the gentleman from 
Oregon (Mr. Blumenauer) and ask him to share the great contribution he 
has made and the loopholes we find in the Republican substitute.
  Mr. BLUMENAUER. I appreciate the gentleman's courtesy.
  I hope every American examines the plan that has been offered to us 
by the Republicans.
  Our citizens are outraged by practices of taking away insurance when 
you need it or denying coverage for preexisting conditions. Our bill 
fixes it. You won't find it in the Republican bill. Republicans strip 
out provisions so important to Oregon and other low-cost, high-quality 
States. Republicans do not deal with those vast regional disparities.
  They ignore the extra costs faced by seniors caught in the 
prescription drug doughnut hole while Democrats provide financial 
relief within the next 2 months. If Republicans have their way, there 
will be more uninsured Americans in 10 years than there are today. 
Weaker protections ignore the needs of the most vulnerable, yet the CBO 
says the Republican plan will increase the deficit by $36 billion more 
than the Democratic plan.
  Mr. Speaker, this is a colossal failure of imagination. The 
Republicans could have passed this package any time during the 6 years 
they and George Bush ran everything. They didn't bother because it 
wasn't worth it.
  Last March, Republican Minority Leader Boehner famously said that his 
Members shouldn't legislate. With this package as the best they could 
do, the Republicans have met the challenge not to legislate.
  Mr. CAMP. Mr. Speaker, at this time, I yield 3 minutes to the 
gentleman from Missouri (Mr. Blunt).
  Mr. BLUNT. Mr. Speaker, I thank the gentleman for yielding.
  The Republican Congresses did send important parts of this plan, the 
House, to the other body. We sent lawsuit abuse reform seven times. We 
sent associated health plans at least a half dozen times. They didn't 
get to the floor. We continue to send the elements of this plan that 
save every taxpayer money and also save every insured American money. 
This is the only plan that reduces the cost of insurance for every 
group of insured Americans.
  One of the goals that the President set for health care reform was to 
reduce the cost of premiums. This is the only plan that does that. It 
does it for individuals. It does it for small businesses. It does it 
for large groups.
  This is a plan where we could provide access to coverage for everyone 
regardless of preexisting conditions. Now, we don't spend $1.3 trillion 
to do that. We spend about $23 billion to make the risk pools work 
better and ensure access for everybody. We're for access for everybody 
to coverage; we're just not for spending $1 trillion to create that 
access.
  This plan lowers premiums. It prohibits insurance companies from 
canceling policies. It prohibits insurance companies from capping the 
lifetime expenditures that those policies might incur.
  One of the reasons that there were more people uninsured at the end 
of the 10 years under this plan is, when our friends on the other side 
insisted on the children's health insurance plan, they put everybody 
that goes on that plan in the first 5 years back into no insurance in 
the last 5 years. Look at the numbers. That's where those numbers go 
up. You could pretend that our plan puts the numbers up. We're not the 
one that said we're going to insure all children for 5 years and in the 
second 5 years they're back to where they are today. Check the numbers. 
Look at what this does for premiums. Look at what this does for 
families. Look at what this does for individuals.
  This is a plan that truly does keep what works and fixes what's 
broken. The President repeatedly has said, Everyone, if you like what 
you have, you should be able to keep it. This is the only plan that 
would allow that pledge to be made and be kept.
  Mr. Speaker, I encourage my colleagues to support this plan. Let's 
take these first steps that work without bankrupting the American 
people. I urge support of this plan.
  The SPEAKER pro tempore. The gentleman from New York has 3\1/2\ 
minutes remaining.
  Mr. RANGEL. Mr. Speaker, I yield 2 minutes to the gentleman from 
Wisconsin, Ron Kind, and thank him for the great contributions he has 
made to looking at health care the way it should be, and that is value 
and not volume.

[[Page 27562]]



                              {time}  2100

  Mr. KIND. Mr. Speaker, let's be clear. We really face three choices 
here tonight: our plan, their plan, and the consequences of doing 
nothing.
  But we know what inaction will bring already. We will pay more, we 
will get less, and we will bankrupt ourselves as a Nation due to rising 
health care costs. So let's just take a moment and compare the two 
plans before us this evening.
  According to the Congressional Budget Office, not only is our health 
care reform plan completely paid for, but we reduce the national 
deficit by $109 billion in the first 10 years alone; they by only $68 
billion. We cover an additional 36 million uninsured Americans in this 
country; they increase the number of uninsured from 47 million today to 
over 52 million by 2019. We cover 96 percent of Americans under our 
plan; they, 83 percent. We give small businesses tax credits to use in 
the national exchange to make it more affordable for them; they do 
nothing. We ban the discrimination based on preexisting conditions; 
they do nothing. We close the doughnut hole for seniors in Medicare; 
they do nothing.
  But, most importantly, they do nothing to reform how health care is 
delivered and how we pay for it in this country. We change the fee-for-
service payment under Medicare, which is all volume based, to a 
reimbursement system that rewards quality and the value of care. Why is 
this important? Because studies show that we are spending over $800 
billion every year on tests and procedures that don't work. They don't 
improve patient care, and because of overtreatment in too many 
instances, we're making patients worse off rather than better off.
  Our payment reform plan has the best potential of increasing the 
quality of care for all Americans at a substantially lower price. They 
do nothing.
  Mr. Speaker, just 2 months ago President Obama stood in this Chamber 
and reminded us what the true character of the American spirit is all 
about. He reminded us that we did not come here to fear our future, but 
to shape it. That is the historic opportunity that we have before us 
this evening.
  The SPEAKER pro tempore. The time of the gentleman has expired.
  Mr. RANGEL. I yield the gentleman an additional 30 seconds.
  Mr. KIND. I thank the gentleman.
  I ask my colleagues to support true reform and provide all Americans 
with access to affordable and quality care that they all deserve.
  Mr. RANGEL. Mr. Speaker, I yield myself the balance of my time.
  I'm not going to be as difficult with the Republicans as some of my 
colleagues because I'm glad at the end of the day they finally 
understood the problem. And even though it was only Tuesday that they 
actually put something together for us to look at, at least we know 
that some of them are going in the right direction.
  It's going to be tragic to explain this to the American people not 
only now but in the future as to when they had a great opportunity. 
They lost it on Social Security. They said government would become too 
big. They lost it on Medicaid. They said that would be too much for the 
poor folks, that they should have freedom instead of health care. And 
they certainly lost it in Medicare where they made it appear as though 
it was going to be a Big Government takeover.
  And now it just seems to me that they've proven how well government 
can do in these programs. And the fact that in lieu of just plain 
freedom, in lieu of telling people that they can get insurance if 
they're at risk, the whole idea that they're proud of people who cannot 
afford to do this at least to have the opportunity to do it.
  So, Mr. Speaker, I just hope that some of those on the other side 
might allow morality to go beyond just party loyalty.
  At this time it gives me pleasure to present to this body Chairman 
Waxman, who has done so much to make this a reality.
  Mr. CAMP. Mr. Speaker, I reserve the balance of my time.
  Mr. WAXMAN. Mr. Speaker, I'm pleased to yield 1 minute to the 
gentleman from Vermont (Mr. Welch).
  Mr. WELCH. Mr. Speaker, tonight the question before Congress is 
neither new nor complicated: Will we do what it takes to make health 
care affordable and available to all Americans?
  Our predecessors in Congress faced similar choices when they extended 
voting rights to all Americans, established Social Security and 
Medicare for all seniors. Mr. Speaker, Congress faced those challenges 
and we are the better for it. We did so not without conflict and 
controversy but with some bipartisan support.
  Tonight is different, unique. Our Republican friends have assured us 
that not a single member of their caucus will vote for health care 
reform. Every single person will vote ``no.''
  The Republicans' alternative says to Americans with a preexisting 
condition, you are on your own. To the 47 million Americans without 
insurance, you're on your own. To the millions of Americans who can't 
afford the coverage that they have, you're on your own.
  Our health care bill has a different philosophy, the one that 
prevailed when Democrats, and some Republicans, passed Social Security, 
voting rights, and Medicare: We are in it together.
  Mr. WAXMAN. Mr. Speaker, I'm pleased to yield 2 minutes to a very 
distinguished member of our committee, the chairman of the Energy 
Subcommittee, previously chairman of the Telecommunications 
Subcommittee, and a very highly respected Member of this body, the 
gentleman from Massachusetts (Mr. Markey).
  Mr. MARKEY of Massachusetts. The Republican plan is really quite 
simple: you're on your own.
  The Republican plan tells Americans if you get sick and you don't 
have insurance, you're on your own. The Republican plan tells Americans 
if you are denied coverage because of a preexisting condition, you're 
on your own.
  The Republican leaders in Washington seem to be suffering from their 
own preexisting condition: a heart of stone. If you kicked them in the 
heart, you would break your toe.
  They say that the Democratic plan will put the government between you 
and your doctor, but the doctors who make up the American Medical 
Association support the Democratic bill and not the Republican bill. 
The Republicans claim the Democratic bill will hurt seniors, but AARP 
has endorsed the Democratic bill and not the Republican bill. Why does 
AARP support the Democratic bill? Because the Democratic bill will 
close the Medicare part D doughnut hole for seniors. The Republican 
bill does not. We provide support for low-income seniors; they do not. 
We will extend the solvency of Medicare; they do not. Right now 60 
percent of all bankruptcies in America are because of medical expenses. 
The Democratic bill makes sure that never happens again; the Republican 
bill does not.
  You know, the GOP used to stand for Grand Old Party. Now it stands 
for ``grandstand, oppose, and pretend.'' They grandstand with phony 
claims about nonexistent death panels. They oppose any real reform. And 
with this substitute they pretend to offer a solution while really 
doing nothing. GOP: grandstand, oppose, and pretend.
  And make no mistake about it, the Republican substitute is not real 
reform. It does nothing to curb skyrocketing health care costs. It does 
nothing to provide real insurance coverage to millions who are now 
uninsured. It does nothing to stop the unfair practices of insurance 
companies.
  I urge my colleagues to vote ``no'' on the Republican ``do-nothing'' 
substitute.
  Mr. CAMP. Mr. Speaker, I yield 1 minute to the gentleman from Florida 
(Mr. Mica).
  Mr. MICA. Mr. Speaker, this is a sad day for the Congress and 
particularly a sad day for Americans who lack health care coverage. 
While Democrat efforts to resolve health care problems may be well 
intended, in fact they totally miss the mark. People want lower 
premiums, increased access, less cost, and less red tape. They want 
choice and quality health care.

[[Page 27563]]

  Instead, the Democrat health care plan dramatically expands 
government, cuts Medicare, and imposes significant costs to taxpayers. 
The creation of 118 new Federal programs, agencies, and czars adds 
bureaucracy and red tape rather than providing a cure to bring health 
care costs down and accessibility up. The $729 billion in new taxes on 
Americans and small businesses will result in a loss of 5.5 million 
more jobs at a time when our country can least afford it and 
unemployment has topped a record 10.2 percent.
  I oppose the cuts of nearly a half trillion dollars in Medicare. This 
is the wrong solution at the wrong time.
  Mr. WAXMAN. Mr. Speaker, I'm pleased at this time to yield 1 minute 
to the gentleman from Texas (Mr. Gonzalez).
  Mr. GONZALEZ. Mr. Speaker, I rise in strong opposition to the 
substitute.
  This substitute includes medical liability reforms that draw on the 
Texas model. I'm from Texas. Let me tell you about the Texas 
experience.
  We were promised that medical malpractice reform in Texas would 
result in attracting doctors to underserved areas. Today, Texas ranks 
43rd out of the 50 States in the number of doctors per capita.
  We were promised that it would rein in health costs. Health care 
costs in Texas with Medicare alone rose 24 percent in the 3 years after 
Texas tort reform.
  We were told that it would reduce the cost of health care insurance 
for Texans. Premiums actually increased 86.8 percent from the years 
2000 to 2007. The average insurance policy for a family in Texas went 
from $6,638 to $12,403.
  We were told that it would make health insurance plans more readily 
available for Texans. Today, Texas has the highest rate of uninsured 
adults and the highest rate of uninsured children.
  If ever there was a time not to mess with Texas, it is tonight. Vote 
``no'' on the substitute.
  Mr. WAXMAN. Mr. Speaker, I'm pleased at this time to yield 2 minutes 
to the gentleman from New York (Mr. Weiner), an important member of our 
committee and a leader in health care reform.
  Mr. WEINER. You know, there are honorable people on both sides of 
this debate; but there are moments that come along, and they come along 
about every generation or so, that make it clear why this side of the 
aisle are Republicans and why we're Democrats.
  In 1935 when there was the Social Security Act and we decided we 
weren't going to allow 30 percent of seniors to slip into poverty, 
Democrats proposed, Democrats passed; Republicans opposed Social 
Security.
  In 1965 when Medicare was passed, Democrats proposed, Democrats 
supported; Republicans opposed, and now Medicare is a fact of life. And 
the very same arguments that were made against Medicare then are being 
made tonight.
  I hear this talk about the single-payer plan that's going to creep 
over. I can tell you I wanted a single-payer plan. I would like it to 
be there, but it's not. But you opposed it then, and now you claim to 
support it.
  There's been a lot of talk about how big the bill is, but here's what 
it's all about: this is what Members of Congress get. This is a 
guidebook with affordable health care plans, many choices, deep 
discounts because we pool people together, minimum standards for each 
plan. This is what Members of Congress get, but they don't want you, 
the American people, to get it.
  This is what it's about: they say they want to protect Medicare, but 
it was they who wanted to eliminate it. They say they want to protect 
Social Security. It was they who wanted to privatize it. Now they say 
we don't want to cover those who are uninsured because you shouldn't 
care.
  Well, I say to my colleagues, who pay those bills? The bill fairy? 
Who pays those bills are you, the taxpayer. They say they want you to 
pay those, too.
  When you look at how big the bills are, remember this document. Eight 
million Americans who work for the Federal Government, including my 
colleagues, get this document in the mail. They get good health care. 
We want it for you. They're going to get Medicare at 65. They don't say 
we don't want Medicare because we don't believe in single-payer. They 
want it because they want to take and take and take, but they don't 
want it for you.
  The Democrats want this for you and the Republican Party just wants 
it for themselves.

                              {time}  2115


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair would remind Members to address 
their remarks to the Chair.
  Mr. CAMP. Mr. Speaker, I yield myself 15 seconds.
  As a Senator from Maine who voted for the Senate finance bill 
remarked on the House legislation pending said, I do not know what 
world they live in, but all I know is it is totally detached from the 
average person, the average business owner who is struggling to keep 
their doors open, and to have that level of taxation is breathtaking in 
its dimension. I just think it is so out of proportion with reality, 
with Main Street, America, that it is hard to believe, frankly.
  I now yield 5 minutes to a distinguished member of the Ways and Means 
Committee, the distinguished minority whip from Virginia (Mr. Cantor).
  Mr. CANTOR. Mr. Speaker, today brings the culmination of an extensive 
and spirited debate over health care reform. Both parties agree that 
the status quo is unacceptable. Obviously, we disagree on how to fix 
what is broken. And as the gentleman from New York just said, there are 
times in this body when we really can tell the difference between us 
Republicans and you Democrats, and this is certainly one of them.
  Mr. Speaker, the Democrat solution is a 1,990-page, trillion-dollar 
overhaul of the health care system we know, a sweeping new entitlement 
that raises taxes, cuts benefits to seniors and, Mr. Speaker, it spends 
over a trillion dollars that we don't have.
  Republicans believe there is a better way. We have proposed an 
alternative approach that offers a stark contrast to the majority's 
plan. It is a fiscally responsible and reasoned approach.
  The majority's proposal overturns the whole system. We keep what 
works and then try to fix what is wrong.
  Their bill puts the government between families and their doctors. 
Ours doesn't.
  Their plan cuts Medicare benefits to seniors. Ours retains them.
  Their proposal blows a hole in the deficit. Ours actually saves 
money.
  Their bill imposes penalties and mandates on our small businesses 
that cost jobs. Ours does not.
  Specifically, Mr. Speaker, our bill will help you access health care 
if you lose or change your job. And it will ensure that you have access 
to medical care if you have a preexisting condition. And we also, Mr. 
Speaker, deliver on something that the majority refuses to even talk 
about, and that's real, meaningful medical liability reform.
  And most importantly, Mr. Speaker, we produce cost savings for 
workers, families, and small businesses. The Congressional Budget 
Office says that the Democrats' new government-run system won't reduce 
costs. CBO says our legislation lowers health care costs. In fact, CBO 
says that the Republican plan cuts premiums by up to 10 percent for 
employees covered by small businesses, up to 8 percent for those not 
covered by employers, and up to 3 percent for employees covered by 
large businesses.
  Mr. Speaker, in the face of 10.2 percent unemployment, Americans want 
jobs. They want less government spending and more economic security. 
The majority's bill shows they have not listened. Ours shows we have.
  Interestingly, Mr. Speaker, the only bipartisanship on Capitol Hill 
today will be in opposition to Speaker Pelosi's trillion-dollar-plus 
government overhaul of America's health care system.
  With that, Mr. Speaker, I urge passage of this substitute.
  Mr. WAXMAN. Mr. Speaker, I ask unanimous consent that the 2 minutes 
that has been reserved for the Education and Labor Committee debate

[[Page 27564]]

time in opposition to the Republican substitute be transferred to the 
Energy and Commerce Committee's time.
  The SPEAKER pro tempore. Is there objection to the request of the 
gentleman from California?
  There was no objection.
  Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the 
gentlewoman from the District of Columbia (Ms. Norton).
  Ms. NORTON. Mr. Speaker, I thank the gentleman for yielding and for 
the extraordinary work that he and others have done on this bill.
  The extraordinary diversity of our Democratic Caucus, Mr. Speaker, 
from right to left, has ensured that this bill represents a cross-
section of our country, urban, suburban and rural. The incredible 
diversity of our Democratic Caucus, representing Republicans, right-
leaning, moderate, and progressive areas meant that we could not come 
to this floor today without a bill that sensitively put all of America 
together into one convincing bill. That is why we have produced a bill 
that satisfies deficit hawks who are more wary of increasing deficits 
than of most other issues, as well as single-payer advocates who 
believe that only Medicare for all can markedly reduce costs while 
providing adequate health care for the middle class and the uninsured.
  Thus, there can be no doubt this evening that the Affordable Health 
Care for America Act is a balanced bill and the best bill for the 
citizens of the United States of America.
  The extraordinary diversity of our Democratic Caucus--from right to 
left has ensured that this bill represents a cross-section of the our 
country--urban, suburban, and rural. The incredible diversity of our 
Democratic Caucus, representing Republican, right-leaning, moderate, 
and progressive areas, meant that we could come to this floor today 
only with a bill that sensitively put all of America together into one 
convincing bill. That is why we have produced a bill that satisfies 
deficit hawks, who are more wary of increasing deficits than of most 
other issues, as well as single-payer advocates, who believe that only 
Medicare for all can markedly reduce costs while providing adequate 
health care to the middle class and the uninsured. Thus, there can be 
no doubt that the Affordable Health Care for America Act is the best 
bill for the citizens of the United States of America.
  The bill's greatest achievements are that it would reduce the deficit 
over the next 10 years and into the future while covering 96 percent of 
the American people; would end discrimination by insurers who dropped 
or refused to renew or sell coverage because of health status and would 
ensure that coverage is affordable by providing subsidies for people in 
employer-based health care or through an insurance exchange of private 
insurers and a consumer option to drive down the cost of health care 
while operating on a level playing field with other insurers.


                         Parliamentary Inquiry

  Mr. GOHMERT. Parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. GOHMERT. Mr. Speaker, my understanding of the rules is that there 
is required to be a copy of the bill, and since we have a manager's 
amendment, that is supposed to be somewhere. A number of us have been 
trying to find a copy of the manager's amendment since we are going to 
be voting on it. I hear some aahs, but isn't there supposed to be a 
copy, and if so, where would that copy be, since we are about to do 
this to the American people?
  The SPEAKER pro tempore. The official papers are at the desk.
  Mr. GOHMERT. And I was just at the desk, Mr. Speaker, so 
parliamentary inquiry: If you could direct me to that place on the desk 
where the 200 pages are, it would be very helpful.
  The SPEAKER pro tempore. The Clerk has the official papers. 
Additional copies are in the lobby and Members have been carrying them 
around all day.
  Mr. GOHMERT. Parliamentary inquiry. Does the Speaker know where a 
copy, as the rule requires, is at the desk so that we can come up and 
see it at the desk as a requirement of the rules?
  The SPEAKER pro tempore. The Clerk has custody of the official 
papers.
  Mr. GOHMERT. I take that as a ``no.''
  The SPEAKER pro tempore. The gentleman from Michigan has 4 minutes 
remaining, and the gentleman from California has the right to close.
  Mr. CAMP. We will reserve our time.
  Mr. WAXMAN. We are ready to close, so use your time. Use it or lose 
it.
  Mr. CAMP. At this time, Mr. Speaker, I yield the customary 1 minute 
to the distinguished minority leader, the gentleman from Ohio (Mr. 
Boehner).
  Mr. BOEHNER. Let me thank my colleague for yielding, and thank him 
and our ranking members for the job they have done putting our 
substitute together.
  Ladies and gentlemen, before I came here, I ran a small business. 
While I was running my small business, it became pretty clear to me 
that government was growing in my view out of control. More 
regulations, more taxes, more compliance costs, both for my suppliers, 
for my customers, and for my own little small business. It seemed to me 
that government was choking the goose that was laying the golden egg.
  You know, we were all lucky enough to be raised in America, most of 
us born in America, the greatest country in the world. And it is a 
great country because Americans have had the freedom, the freedom to 
succeed, the freedom of opportunity. But I think all of us can 
understand that the bigger government gets, the more that it takes from 
the American people, the more money that individuals have to spend to 
comply with all of these regulations, is less money that is left in 
American families' pockets, small business's pockets, and as a result 
the opportunities, the opportunities available for our citizens get 
diminished.
  We live in a great country. But it can only be great if we are 
willing to allow the freedom that Americans have had to succeed to 
remain. That freedom has been dimming. The bright lights of freedom 
have been dimming for decades because government continues to grow. One 
only has to look at what has happened this year to wonder why we are 
here tonight doing this. We all know we have had a difficult economic 
shock in our country over the last year.
  So we see a stimulus bill that came to this floor with a promise that 
we were going to create jobs, jobs, jobs. And unemployment wasn't going 
to exceed 8 percent. Now we have unemployment rates at 10.2 percent and 
over 3 million Americans have lost their jobs. So all of a sudden we 
have a budget on the floor, a trillion-and-a-half-dollar deficit this 
year, and trillion-dollar deficits on average for as far as the eye can 
see. And I don't think there is a Member on either side of the aisle 
who doesn't realize that this is unsustainable, that this will wreak 
havoc on our country and wreak havoc on the future for our kids and our 
grandkids.
  If there is one obligation that we have, it is to ensure that the 
American dream that is available to all of us is available for our kids 
and our grandkids. And trillion-dollar deficits for as far as the eye 
can see are not sustainable and will ruin their future.
  But no, it wasn't enough. All of a sudden we have to have this 
national energy tax on the floor in June. It is called cap-and-trade 
because no one in America really knows what that means, but it is a 
giant energy tax. And it would tax anybody who drives a car, anybody 
who works at a place that uses electricity. Anyone who would have the 
audacity to flip on a light switch is going to pay a higher tax.

                              {time}  2130

  Not only are we going to pay higher taxes and have less energy and 
higher energy costs in America, it will ship millions of American jobs 
overseas at a time when Americans are asking, Where are the jobs? And 
the policies that have been coming down the pike all year have done 
nothing more than diminish the possibility that we will be creating the 
jobs that Americans so desperately want. That still wasn't enough. Now 
we are going to bring this 2,000-page bill to the floor of the House. 
It's going to cost over $1.3 trillion and will kill millions more 
American jobs.
  The American people want us to focus on getting our economy moving

[[Page 27565]]

again because they are looking for work. They want to make sure that 
those who have their job can keep it. What has happened here all year 
is we're moving policies that are going to destroy the ability of the 
private sector to create those jobs. But I don't think there is 
anything that will diminish the job prospect in America more, of all 
the things that have happened this year, than this health care bill.
  Now, you just think about this bill that we have in front of us. It 
is going to raise taxes. It is going to raise insurance premiums for 
those who have insurance. It's full of mandates. And as if that's not 
enough, we are going to cut Medicare.
  Now, the President said that if you like the health insurance you 
have, you can keep it. And I know the President was sincere in that, 
but that is not what this bill represents and there's not a Member in 
this Chamber that doesn't understand that. Because if you're a Medicare 
Advantage enrollee, like 27,000 of my constituents, the Congressional 
Budget Office says that 80 percent of them are going to lose their 
Medicare Advantage.
  If you look at this bill and you look at the employer mandate in this 
bill, you will find out that if employers don't provide health 
insurance, there is a tax. And for many employers, the tax will be 
cheaper than the actual cost of health insurance. A lot of employers in 
America are going to look up and say, Listen, I'd rather pay the tax, 
and my employees are going to have to go fend for themselves and end up 
in the government plan.
  But it doesn't stop there. This bill also requires that every 
employer plan that is offered today has to be approved once again by 
the Department of Labor and the health choices czar; big compliance 
cost there. Some employers are going to say, Listen, this isn't worth 
it. Because it's not just getting the plan reapproved again. It has to 
go through the health choices czar so that the health choices czar can 
determine whether your plan is adequate according to some Federal 
bureaucrat. And so a lot of employers, they're just going to get out of 
it. They're not going to do it. And what is going to happen to those 
employees who like the coverage they have today? They are going to end 
up in the government plan.
  But no, no, it doesn't stop there. We have an individual mandate in 
this bill in front of us that says every American is going to buy 
health insurance whether you want it or not. And if you don't want it, 
you're going to pay a tax. And if you don't pay the tax--listen to 
this. If you don't pay the tax, you're going to be subject to a fine of 
up to $250,000 and imprisonment up to 5 years. Now, this is the most 
unconstitutional thing I've ever seen in my life. The idea that we can 
tell Americans, force Americans by some law that they have to buy 
health insurance or we're going to fine you and send you to jail.
  But there has been all this focus on the employer mandate and on the 
individual mandate, on the government option, but let me tell you where 
there hasn't been much attention, and that is the giant bureaucracy 
that is being built here in Washington in the Federal Government to 
take control of Americans' health care system and force you out of the 
insurance you have and into some government-run plan.
  I know most of my colleagues, they might think this is hyperbole or 
it might sound political. Let me tell you, it isn't. Well, just listen 
to this. Most of my colleagues on the left have been down here today. 
They are for this because it does in fact set up this big 
infrastructure for the government to eventually take control of all of 
our health care and just go to a single-payer system.
  Now, it starts with the exchange that's in this bill. Once it takes 
effect, the health exchange, you can't buy private insurance on your 
own. You can't go out and buy insurance. You have to go to the 
exchange, and the exchange will decide for you which plans are offered 
to you. So, if you change your job or you don't like what you have, 
guess what? You get to go to the government's health exchange to get 
your insurance.
  But it's just not the government option that I'm talking about. When 
you look at this infrastructure that's there, it is going to require 
tens of thousands of new Federal employees. The American people want 
two things from health care reform: They want lower cost and they want 
more choices. I think the underlying bill here tonight does exactly the 
opposite. It raises the cost of health insurance and creates this new 
megabureaucracy to make health care decisions that should be left to 
doctors and their patients.
  So let's talk about this bureaucracy for a moment. If you go to page 
131, section 241 provides for an unelected ``Health Choices 
Commissioner'' who would run a ``Health Choices Administration,'' an 
independent agency of the executive branch.
  Now, here are some of the examples of the powers of this new health 
choice commissioner--let's just call him the health czar. On page 167 
through 172, in section 303, the health czar will decide which 
treatment patients could receive and at what cost. Or you can go to 
page 132, section 242, the health choices czar would decide which 
private plans would be allowed to participate in the exchange.
  Then you go to page 127, section 234. This new health czar will 
regulate all insurance plans both in and out of the exchange.
  Then you go to page 162 to 165, section 302, the health choices czar 
will determine which employers are going to be allowed to participate 
in the exchange.
  Then you go to page 174 to 178, section 304(b), the health choices 
czar will decide which physicians and hospitals get to participate in 
the government-run plan.
  Then you go to page 197 to 202, section 308, the health choices czar 
will determine which States are allowed to operate their own exchange 
and to terminate any previously approved State exchange at any time.
  Then you go to page 170 and 171, section 303(d), the health choices 
czar can override State laws regarding covered health benefits. It's in 
the bill. Go read it.
  Page 133, section 242(a)(2). This person will determine how trillions 
of taxpayer and employer dollars would be spent within the exchange.
  And page 133, section 242, ``conduct random compliant audits.'' The 
person still has more powers here.
  Page 183, section 305, automatically enroll Americans into the 
exchange if they don't have coverage, including potentially forcing 
these individuals into the government-run plan. Now, this is referred 
to as ``random assignment.''
  This commissioner is charged with establishing ``waiting lists'' and 
defining such terms as ``dependent,'' ``service area,'' ``premium 
rating area,'' ``employee,'' ``part-time employee,'' and ``full-time 
employee.'' Let's all be honest, this is the czar to end all czars.
  But it doesn't stop there. When you look at this expanding 
bureaucracy created in the Federal Government, on page 1322, section 
2401, it creates a new Center for Quality Improvement to prioritize 
areas for identification, development, evaluation, and implementation 
of best practices for quality improvement of best practices for the 
delivery of health care services. We've already got Centers for Quality 
Improvement. We've got doctors, nurses, surgeons, hospitals, 
laboratories, rehab facilities. But no, no, we're going to have more 
bureaucracy than that. We're not even close to the end of this 
bureaucracy.
  Page 1183, section 1904 provides for $750 million in Federal funding 
for a new entitlement program to offer ``knowledge of realistic 
expectations of age-appropriate child behaviors'' and ``skills to 
interact with their child.'' So not only is the Federal Government 
going to legislate what's good for medical practices, now we're going 
to put $750 million into a program to help legislate how parents should 
parent.
  Page 1198, section 1907, we establish a Center for Medicare and 
Medicaid innovation within the Centers for Medicare and Medicaid 
Services to legislate innovation as part of a bill that cuts, I think, 
the most innovative Medicare program we have, that's Medicare 
Advantage. But we still have more.

[[Page 27566]]

  Page 25, section 101 authorizes the Secretary of Health and Human 
Services to reduce benefits, increase premiums, and establish waiting 
lists to make up for funding in the shortfalls of high-risk pools. 
That's right there in the bill, ``establish waiting lists.''
  Pages 734, 738, and 1162, sections 1401 and 1802 create the Center 
for Comparative Effectiveness Research and the Comparative 
Effectiveness Research Commission and the Comparative Effectiveness 
Research Trust Fund. These are bureaucracies that will decide which 
treatments are most effective. But the bill does not provide any 
protection to doctors and patients that they all get to decide what's 
in their own best interest.
  Then we get into a lot more duplicative Federal programs. Page 1432, 
section 2531 provides for incentive payments to States that enact new 
medical liability laws, but only if such laws do ``not limit attorneys' 
fees or impose caps on damages.'' So we're telling States to solve the 
problems, but also telling them not to use the tools that work most 
effectively in the States that are using them.
  Page 1624, section 2589 creates a new Personal Care Attendant 
Workforce Advisory Panel. Let me say that again, a Personal Care 
Attendant Workforce Advisory Panel made up in part by personal care 
workers, including their union representatives, to study working 
conditions and salaries of these workers. What does this have to do 
with lowering health care costs?
  Page 1968, section 3103 establishes a ``Committee for the 
Establishment of the Native American Health and Wellness Foundation.'' 
So we're going to set up a committee whose job it is is to set up a 
foundation, and we're going to take half a million dollars of 
Americans' money to do this.
  Page 1330, section 2402 creates a new Assistant Secretary for Health 
Information. I guess this is another job saved or created.
  Page 1391, section 2524 creates a ``No Child Left Unimmunized Against 
Influenza'' demonstration grant program to test the feasibility of 
using the Nation's elementary schools and secondary schools as 
influenza vaccination centers. Aren't we doing this already?
  Page 1253, section 2231 creates a new Public Health Workforce Corps 
for the purpose of ``ensuring an adequate supply of health 
professionals.'' The bill also creates a ``Public Health Workforce 
Scholarship Program'' and a ``Public Health Workforce Loan Forgiveness 
Program.'' All of this duplicates the existing National Health Services 
Corps.
  Page 1478, section 2552, the bill creates an Emergency Care 
Coordination Center in the Office of the Assistant Secretary for 
Preparedness and Response charged with working in coordination with the 
Federal Interagency Committee on Emergency Medical Services. And the 
Emergency Care Coordinator Center seeks out the advice of a Council of 
Emergency Care.
  We're not finished yet. How about this one? Page 1515, section 
2572(b) imposes a labeling requirement on all vending machines 
nationwide. In addition to that, we require all restaurants with more 
than 20 locations to post the calorie count exactly next to--and we 
spell this in the law--right next to the menu, whether it's the drive-
in menu, the menu on the board, the one they hand out to you. Oh, yeah. 
We're going to require every restaurant with more than 20 locations to 
do this. Oh, but that's not enough.

                              {time}  2145

  Page 872, section 1433 requires the director of food services at 
nursing facilities that participate in Medicare or Medicaid to hold 
``military, academic, or other qualifications'' as determined by 
Federal bureaucrats. So now we are going to legislate the work 
requirements in the background of all this off.
  But I think this is the best part of the bureaucracy: on page 122, 
section 233(a)(3) of this 2,032-page bill, it requires the commissioner 
to ``issue guidance on best practices of plain language writing.'' Oh, 
yes, it's right here in the bill. Go look at it.
  Ladies and gentlemen, we know what's going on here. There are 
problems in our current health care system that we all want to address. 
I heard all the criticisms of our bill and the fact that it doesn't do 
everything that everybody wants it to do.
  But do you know what it does do?
  It lowers the cost of health insurance, and it solves the problem of 
those with preexisting conditions, and it begins to insure more 
Americans. That's what the American people want, a step-by-step 
approach to making the best health care system in the world better. We 
can do that. What we don't need to do is to create this giant 
bureaucracy, spend all of this tax money, and imprison our children's 
future by passing this 2,000-page bill.
  So, I think we do have a better solution, a commonsense solution that 
Americans will support.
  So, tonight, here we are. We have a choice. We can pass the 2,000-
page bill. We can raise taxes. We can cut Medicare. We can impose all 
of these mandates on employers that are going to drive employment down 
and unemployment up, or we can take some commonsense approach.
  As I said during my remarks, our job is to do our best to make sure 
that our kids and grandkids have a better chance of the American Dream 
than we did. I understand that we've got some tough choices to make, 
but that's what the American people sent us here to do is to make those 
tough choices. I'm not going to put my kids further in debt. I'm not 
going to dim the lights of freedom for my kids and theirs nor for 
anyone's in this country if I can avoid it.
  So we have a choice. We can do what's right for the future, or we can 
continue down this path toward bigger and bigger government. I came 
here to fight for freedom. I came here to renew the American Dream for 
our kids and our grandkids.
  So I would ask my colleagues to think about that choice. Vote for the 
Republican alternative, and whatever you do, please vote ``no'' for the 
underlying bill.
  Mr. WAXMAN. Mr. Speaker, to close the debate on the Democratic side, 
I yield the balance of my time to the dean of the House, to the lead 
author of the underlying bill and to a man who has fought longer for 
national health insurance than anyone in this institution. I yield the 
balance of my time to Representative John Dingell from the State of 
Michigan.
  The SPEAKER pro tempore. The gentleman from Michigan is recognized 
for 5 minutes.
  Mr. DINGELL. Mr. Speaker, I am here tonight to urge my colleagues to 
vote against the Republican substitute and for the bill reported by 
three committees after long and hard work.
  I want to tell the House--all Members--how proud I am of the 
discussion that has taken place today. I want to commend the three 
committees and their chairmen, including my good friend, the chairman 
of our committee, Mr. Waxman, for the work they have done.
  You, Madam Speaker and the leadership, we thank you for the 
extraordinary leadership which you have given us in bringing this to 
the point where we are tonight. Thank you.
  I won't begin by spending much time on the bill offered by my 
Republican colleagues. It is really no substitute for H.R. 3962. 
According to The New York Times--and I think this sufficiently disposes 
of the matter--the Republican amendment does ``almost nothing to reduce 
the scandalously high number of Americans who have no insurance, and it 
makes only a token stab at slowing the relentlessly rising costs of 
medical care.''
  Interestingly enough, under the Republican amendment, individuals 
would pay up to $2,821 more, and families would pay up to $8,188 more 
under the Republican plan when compared with H.R. 3962. It's not in the 
public interest that we should do that.
  Having said that, this is historic legislation. It addresses two of 
the most terrifying problems we have in this country:
  The first is what was the problem when my dad introduced the first 
legislation in 1943, that there are now some 47 million Americans 
without health care. This will give many of them adequate health care 
and a decent choice

[[Page 27567]]

of what they will have before them at the best possible price through 
an exchange, which will make it possible for them to choose without 
having to worry about understanding the language of Philadelphia 
lawyers and reading fine print that can only be read with a magnifying 
glass.
  The bill does something more. It takes care of an economic problem 
that will be visited on us in 2080 when the costs of health care will 
equal the gross domestic product of the United States. That will bring 
us to a fine economic mess if we permit that to happen. Health care and 
GDP costs will be equal.
  Now, the bill carries out the President's suggestions: deficit 
neutral. It provides coverage for 96 percent of Americans. It offers 
everyone, regardless of income, age, health status, the peace of mind 
that comes from knowing that they will have real access to affordable 
health insurance when they need it.
  It does away with preexisting conditions, which the bill offered by 
my friends in the minority does not; and it sees to it that, when you 
go to bed at night, you're going to wake up knowing in the morning that 
you're going to have health insurance. It can't have been dropped by 
your employer, and it can't have been canceled by your insurance.
  There is a practice, on which we just had hearings, that is engaged 
in by the insurance companies. It is called ``rescission.'' They can 
cancel your insurance policy by the simple device of rescinding your 
policy because they say you have some preexisting conditions, and they 
can do it while you're on the gurney, being rolled into the operating 
amphitheater.
  The bill is going to give choice and honest competition. It is going 
to bring security to our seniors, and it is going to reduce out-of-
control health care costs that are crushing American business.
  It costs $4 an hour less to make a car in Canada than it does in 
Michigan. Why? Because the Canadians have a program of national health 
insurance which ensures that the manufacturer can compete and out-
compete Americans because he doesn't carry that economic burden.
  Today, this may be a tough vote, but it was in 1935 when we passed 
Social Security. I hear my colleagues tell us that the economy, jobs 
and financial system overhaul, are desperately needed. True. But that 
was the case in '35 when we passed the Social Security Act.
  Now I hear my Republican colleagues tell us this is going to stand 
between--or permit a government bureaucrat to stand between the insured 
and the doctor and each other. In point of fact, it is going to permit 
the government to stand between the insurance bureaucrat and the 
insured, and it is going to stand between him and the doctor so that 
the doctor can provide the care he wants.
  The problems this historic legislation aims to address are real and 
worsening for American citizens, business, and governments. When my Dad 
introduced this legislation sixty some years ago, it was a simple 
humanitarian problem. Today it is one of impending economic disaster to 
America.
  H.R. 3962 meets the goals President Obama outlined for us earlier 
this year: it is deficit neutral; it provides coverage for 96 percent 
of Americans; and it offers everyone, regardless of income, age or 
health status, the peace of mind that comes from knowing they will have 
real access to quality, affordable health insurance when they need it; 
that preexisting conditions will not bar them from insurance; that loss 
of job or dropping of coverage by employer will not deny insurance.
  This bill will stop discrimination against people with pre-existing 
conditions, and it will stop rescission--the practice in which an 
insurer searches for problems with patients' policies while they are 
waiting on a gurney for emergency care.
  Additionally, this bill will ensure choice and honest competition; 
bring security to our seniors; and will reduce the out-of-control 
health care costs that are crushing American businesses.
  Now is the time for health care reform. We can't afford to wait. We 
must offer big solutions for the big problems that face the American 
people. We must succeed.
  Mr. Speaker, I have heard from a number of my colleagues, and I 
appreciate the fact the vote before us today is a tough vote.
  I understand there are numerous competing issues confronting the 
American people--the economy, jobs, financial system overhaul. That was 
so in 1935 when we enacted Social Security over just about the same 
objections.
  However, we know that no issue has caused the American people to 
suffer longer than the issue of inaccessible health care.
  History and the American people will ask what we did here this day 
when presented with a real opportunity to ease the strain of rising 
health care costs and provide quality, affordable health coverage for 
all.
  Mr. Speaker, the vote for me today will be on behalf of American 
families who are forced to decide whether they will pay the mortgage or 
their health insurance premium.
  My vote today is for American business--big and small. They are 
confronted with the real burden of providing quality health care for 
their workers or fall victim to their foreign competitors.
  My vote today is for the federal government, and state and local 
governments throughout the country which are being stretched to make 
room for larger and larger health bills.
  Mr. Speaker, my vote today is also personal.
  It is a vote to fulfill the legacy left by a little, skinny Polack 
with a broken nose and a mustache who served as a proud Member of this 
distinguished body.
  My father, John D. Dingell, Sr., was a part of the original New 
Dealers--a brand of big thinking Democrats--who believed that health 
care is a right, not a privilege and government had a responsibility to 
protect it people; provide for their basic rights; and ensure 
opportunity for all.
  So, it is in that tradition that I urge my colleagues to act today to 
pass this bill.
  Join with the AMA, the AARP, the Consumers Union, the American Cancer 
Society, the different medical specialist groups, the Nurses and others 
who support this bill.
  Mr. Speaker, we have an opportunity today, to do something meaningful 
for the American people and for American business.
  We can take advantage of this opportunity or we can shirk our 
responsibilites and allow the calamitous situation that faces our 
people to contine to grow out of hand, overwhelm the federal budget, 
force more and more families into bankruptcy, and shift more jobs 
overseas.
  Reform is neither easy nor cheap, but the cost of inaction is far 
greater--in terms of lost lives, quality of life and dollars. If we 
don't reduce costs we face certain economic disaster.
  So, today, we must overcome the naysayers, the loyal opposition, the 
lies about our plan, the fear that causes us to think the status quo is 
the safe thing to do.
  We must overcome all of these things and we must act boldly, with 
conviction, and deliberately--not because of our own righteousness--but 
because there is no other acceptable alternative.
  I urge my colleagues to vote ``yes'' on H.R. 3962 and give the 
American people the relief they so desperately need.
  Ms. RICHARDSON. Mr. Speaker, I rise today to oppose the Boehner 
amendment and in strong support of H.R. 3962, the Affordable Health 
Care for America Act of 2009, because this bill is good for seniors, 
good for women, good for small businesses, and good for all Americans.
  President Theodore Roosevelt proposed national health insurance in 
1908. Forty years later in 1948, President Truman proposed it again. 
Under the leadership of Lyndon B. Johnson and a Democratic Congress, 
Medicare was enacted in 1965 which provided health care for senior 
citizens.
  Today, we write another great chapter in the remarkable history of 
this country. Today, we extend to tens of millions of our fellow 
citizens the security that comes from knowing that they will have 
health care that is there when they need it and won't bankrupt their 
families.
  The health care system we have now is not working for middle and 
working class families, not working for businesses trying to compete in 
a global economy, not working for taxpayers or for the uninsured.
  There are 54 million Americans who are uninsured who need us to 
reform this broken system. One in five Californians are uninsured or 
underinsured. These numbers are staggering and if we do nothing, they 
will only grow worse.
  Mr. Speaker, the Affordable Health Care for Americans Act is the 
answer to the broken health care system. This bill provides American 
families with stability and peace of mind. Never again will they have 
to choose between their health and their livelihood.
  This bill provides American families with higher quality health care. 
It leaves important health decisions up to patients and doctors, not to 
insurance companies.

[[Page 27568]]

  Finally, this bill lowers costs for American families. It eliminates 
co-pays and deductibles for preventive care while putting an annual cap 
on out-of-pocket expenses for American families.
  Now, we need to stop playing politics and focus on actually improving 
people's lives. H.R. 3962 will reform the health care system so that it 
provides quality, affordable coverage that cannot be taken away. It 
eliminates discrimination based on gender and preexisting conditions. 
It eliminates the prescription drug donut hole for seniors. It ends the 
era of no and begins the era of yes for millions of Americans seeking 
coverage.
  The hour is late, and the need is great. I urge my colleagues to vote 
``no'' on the Boehner Amendment and ``yes'' on H.R. 3962.
  Mr. GALLEGLY. Mr. Speaker, I rise in support of the amendment offered 
by Mr. Boehner. I have long supported changes to current health care 
system which reduce health care costs through increased efficiency and 
provide affordable insurance for people with preexisting conditions. 
But, at the same time, any changes to our current system should ensure 
doctors and patients are allowed to make health care decisions--not 
government bureaucrats.
  Therefore, I support real health insurance reform and support the 
version offered by the Minority Leader, which would:
  Lower health care premiums for working families,
  Allow small businesses to join together in order to buy reasonably 
priced health insurance,
  Reduce medical costs by limiting frivolous medical malpractice 
lawsuits,
  Prevent insurers from unjustly cancelling health insurance policies, 
and Establish universal access programs that provide affordable 
insurance for people with preexisting conditions.
  Mr. Speaker, we should not consider changes of this magnitude without 
a complete report from the nonpartisan Congressional Budget Office, 
CBO. The preliminary estimate from the CBO puts the cost of H.R. 3962 
at more than $1.05 trillion, but many independent experts believe this 
bill will actually increase Federal expenditures by more than $1.3 
trillion.
  In addition, this bill would impose $730 billion in new taxes and 
mandates on individuals and small businesses. Most economists, 
including CBO experts, have concluded that these requirements could 
increase unemployment by discouraging businesses from hiring low-wage 
workers. It could also lead to wage stagnation as payroll is diverted 
to comply with new Federal mandates on health care coverage.
  I am also concerned about the impact of this proposal on Medicare 
beneficiaries. H.R. 3962 would cut $400 billion from Medicare over 10 
years, including a $170 billion reduction to Medicare Advantage plans, 
which provides insurance coverage for many seniors.
  Finally, H.R. 3962 does not address the problem of frivolous 
malpractice lawsuits in a meaningful way. These suits lead to the 
practice of expensive, defensive medicine and raise the health care 
expenses of all patients.
  I urge my colleagues to reject H.R. 3962 and support the amendment 
offered by Mr. Boehner.
  Mr. SAM JOHNSON of Texas. Mr. Speaker, today, I want to add my 
support for the Republican substitute amendment, the Common-sense 
Health Care Reform and Affordability Act. This amendment is a patient 
centered solution to healthcare reform that our country can afford and 
that members on both sides of the aisle can support. It also addresses 
the number one concern on the mind of all Americans in this country: 
the high cost of health care.
  The Congressional Budget Office has estimated that this Republican 
substitute amendment would reduce health insurance premiums by up to 8 
percent for those families who currently do not have access to 
employer-provided coverage. My constituents have told me over and over 
again that the cost of healthcare is too high. They need healthcare 
that is more affordable, accessible and available and the Commonsense 
Health Care Reform and Affordability Act provides just that.
  Included in the Republican substitute amendment is my bill, H.R. 
2607, the Small Business Health Fairness Act. This legislation allows 
small businesses to band together to purchase health insurance so they 
can enjoy the same bargaining power large corporations and labor unions 
have at the purchasing table. In all parts of our economy we know that 
buying in bulk reduces the price tag, and healthcare is no different. 
Government-forced healthcare is not the way to solve our health care 
problem. We can and have to do better.
  With almost 60 percent of the uninsured population tied to a small 
business, this provision in the Commonsense Health Care Reform and 
Affordability Act, helps bring access to affordable healthcare to those 
that currently don't have it. Clearly, there are better ways to make 
healthcare more accessible for American families--and this Republican 
substitute is it.
  Real healthcare reform should protect doctors and hospitals from 
frivolous lawsuits, so they can stop practicing defensive medicine and 
instead focus on practicing patient-focused care. This amendment 
extends medical liability reform that has been successful in several 
States to the rest of the Nation, saving lives and saving money.
  Another provision in the Republican substitute amendment I am proud 
to support is the State Innovations Program. The amendment provides 
incentives to States who adopt reforms that reduce the cost of health 
insurance and expand coverage to the citizens of their States.
  This provision allows States the freedom to solve their health 
problems on their own. Speaker Pelosi's health-care bill focuses on the 
Federal Government trying to fix what is broken with our health care. 
But in my great State of Texas, I believe those that are best equipped 
to solve our healthcare problems are Texans. It is time for real reform 
that works and not the same old answers of more money and more 
government.
  Finally, this amendment protects American innovation while ensuring 
patients will have more cutting edge treatment options in the area 
called ``follow on biologics.'' The Commonsense Health Care Reform and 
Affordability Act contains a provision that will create a pathway for 
new, life saving products while maintaining the proper incentives for 
companies to research and strive to discover them. Most importantly, 
this provision will ensure that many of the jobs created in this 
industry will stay in the United States.
  The Commonsense Health Care Reform and Affordability Act is exactly 
the solution the American public has asked Congress to pass. It saves 
money, lowers the cost of health care, protects the patient-doctor 
relationship and keeps the government out of personal healthcare 
decisions. I ask my colleagues to join me in supporting this amendment 
today.
  Mr. CAMP. Mr. Speaker, I yield back the balance of my time.
  Mr. WAXMAN. Mr. Speaker, I yield back the balance of my time.
  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
previous question is ordered on the amendment.
  The question is on the amendment offered by the gentleman from Ohio 
(Mr. Boehner).
  The question was taken; and the Speaker pro tempore announced that 
the noes appeared to have it.
  Mr. CAMP. Mr. Speaker, on that I demand the yeas and nays.
  The yeas and nays were ordered.
  The SPEAKER pro tempore. Pursuant to section 2 of House Resolution 
903, further proceedings on this question will be postponed.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Pursuant to section 2 of House Resolution 
903, proceedings will now resume on the amendments printed in parts C 
and D of House Report 111-330 on which further proceedings were 
postponed, in the following order:
  Amendment printed in part C by Mr. Stupak of Michigan.
  Amendment printed in part D by Mr. Boehner of Ohio.
  The Chair will reduce to 5 minutes the time for any electronic vote 
after the first vote in this series.


                    Amendment Offered by Mr. Stupak

  The SPEAKER pro tempore. The unfinished business is the vote on the 
amendment offered by the gentleman from Michigan (Mr. Stupak) on which 
the yeas and nays were ordered.
  The Clerk will redesignate the amendment.
  The Clerk redesignated the amendment.
  The SPEAKER pro tempore. The question is on the amendment.
  The vote was taken by electronic device, and there were--yeas 240, 
nays 194, answered ``present'' 1, not voting 0, as follows:

                             [Roll No. 884]

                               YEAS--240

     Aderholt
     Akin
     Alexander
     Altmire
     Austria
     Baca
     Bachmann
     Bachus
     Barrett (SC)
     Barrow
     Bartlett
     Barton (TX)
     Berry
     Biggert
     Bilbray
     Bilirakis
     Bishop (GA)
     Bishop (UT)
     Blackburn
     Blunt
     Boccieri
     Boehner
     Bonner
     Bono Mack

[[Page 27569]]


     Boozman
     Boren
     Boustany
     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Cardoza
     Carney
     Carter
     Cassidy
     Castle
     Chaffetz
     Chandler
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Cooper
     Costa
     Costello
     Crenshaw
     Cuellar
     Culberson
     Dahlkemper
     Davis (AL)
     Davis (KY)
     Davis (TN)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Donnelly (IN)
     Doyle
     Dreier
     Driehaus
     Duncan
     Ehlers
     Ellsworth
     Emerson
     Etheridge
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Gordon (TN)
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hill
     Hoekstra
     Holden
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     Kanjorski
     Kaptur
     Kildee
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Lamborn
     Lance
     Langevin
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     Lipinski
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Lynch
     Mack
     Manzullo
     Marchant
     Marshall
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McIntyre
     McKeon
     McMorris Rodgers
     Melancon
     Mica
     Michaud
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Mollohan
     Moran (KS)
     Murphy, Tim
     Murtha
     Myrick
     Neal (MA)
     Neugebauer
     Nunes
     Oberstar
     Obey
     Olson
     Ortiz
     Paul
     Paulsen
     Pence
     Perriello
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Pomeroy
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rahall
     Rehberg
     Reichert
     Reyes
     Rodriguez
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Ross
     Royce
     Ryan (OH)
     Ryan (WI)
     Salazar
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shimkus
     Shuler
     Shuster
     Simpson
     Skelton
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Snyder
     Souder
     Space
     Spratt
     Stearns
     Stupak
     Sullivan
     Tanner
     Taylor
     Teague
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (OH)
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                               NAYS--194

     Abercrombie
     Ackerman
     Adler (NJ)
     Andrews
     Arcuri
     Baird
     Baldwin
     Bean
     Becerra
     Berkley
     Berman
     Bishop (NY)
     Blumenauer
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Carnahan
     Carson (IN)
     Castor (FL)
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Courtney
     Crowley
     Cummings
     Davis (CA)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Edwards (MD)
     Edwards (TX)
     Ellison
     Engel
     Eshoo
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kennedy
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kosmas
     Kratovil
     Kucinich
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Massa
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McMahon
     McNerney
     Meek (FL)
     Meeks (NY)
     Miller (NC)
     Miller, George
     Minnick
     Mitchell
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Nadler (NY)
     Napolitano
     Nye
     Olver
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Pelosi
     Perlmutter
     Peters
     Pingree (ME)
     Polis (CO)
     Price (NC)
     Quigley
     Rangel
     Richardson
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Sires
     Slaughter
     Smith (WA)
     Speier
     Stark
     Sutton
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Woolsey
     Wu
     Yarmuth

                        ANSWERED ``PRESENT''--1

       
     Shadegg
       

                              {time}  2220

  Mr. COHEN and Ms. JACKSON-LEE of Texas changed their vote from 
``yea'' to ``nay.''
  Messrs. SPRATT and LEWIS of California changed their vote from 
``nay'' to ``yea.''
  So the amendment was agreed to.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.


                    Amendment Offered by Mr. Boehner

  The SPEAKER pro tempore. The unfinished business is the vote on the 
amendment offered by the gentleman from Ohio (Mr. Boehner) on which the 
yeas and nays were ordered.
  The Clerk will redesignate the amendment.
  The Clerk redesignated the amendment.
  The SPEAKER pro tempore. The question is on the amendment.
  This is a 5-minute vote.
  The vote was taken by electronic device, and there were--ayes 176, 
noes 258, not voting 0, as follows:

                             [Roll No. 885]

                               YEAS--176

     Aderholt
     Akin
     Alexander
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boustany
     Brady (TX)
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Carter
     Cassidy
     Castle
     Chaffetz
     Coble
     Coffman (CO)
     Cole
     Conaway
     Crenshaw
     Culberson
     Davis (KY)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Granger
     Graves
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hoekstra
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McKeon
     McMorris Rodgers
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Moran (KS)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paul
     Paulsen
     Pence
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuster
     Simpson
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Sullivan
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                               NAYS--258

     Abercrombie
     Ackerman
     Adler (NJ)
     Altmire
     Andrews
     Arcuri
     Baca
     Baird
     Baldwin
     Barrow
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boren
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Bright
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chandler
     Childers
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     Davis (TN)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Edwards (TX)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Gordon (TN)
     Grayson
     Green, Al
     Green, Gene
     Griffith
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holden
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson (IL)
     Johnson, E. B.
     Kagen

[[Page 27570]]


     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kosmas
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Lipinski
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Marshall
     Massa
     Matheson
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McIntyre
     McMahon
     McNerney
     Meek (FL)
     Meeks (NY)
     Melancon
     Michaud
     Miller (NC)
     Miller, George
     Minnick
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy (NY)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Perlmutter
     Perriello
     Peters
     Peterson
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Ross
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Shuler
     Sires
     Skelton
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Tanner
     Taylor
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                              {time}  2228

  So the amendment was rejected.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.
  The SPEAKER pro tempore. Pursuant to House Resolution 903, the 
previous question is ordered on the bill, as amended.
  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. CANTOR. Mr. Speaker, I have a motion to recommit at the desk.
  The SPEAKER pro tempore. Is the gentleman opposed to the bill?
  Mr. CANTOR. Yes, Mr. Speaker, in its current form.
  The SPEAKER pro tempore. Pursuant to House Resolution 903, the motion 
is considered as read.
  The text of the motion is as follows:

       Mr. Cantor moves to recommit the bill, H.R. 3962, to the 
     Committee on Energy and Commerce with instructions to report 
     the same back to the House forthwith with the following 
     amendments:
       Page 1209, after line 15, insert the following new title 
     (and conform the table of contents of division B, and the 
     table of divisions, titles and subtitles in section 1(b), 
     accordingly):

 TITLE X--SENIORS PROTECTION AND MEDICARE REGIONAL PAYMENT EQUITY FUND

     SEC. 1911. FINDINGS.

       Congress finds the following:
       (1) When analyzing the Medicare cuts in division B, The 
     Office of the Actuary (OACT) of the Centers for Medicare & 
     Medicaid Services noted that ``The additional demand for 
     health services could be difficult to meet initially with 
     existing health provider resources and could lead to price 
     increases, cost-shifting, and changes in providers' 
     willingness to treat patients with low-reimbursement health 
     coverage.''.
       (2) When analyzing the Medicare cuts contained in division 
     B, OACT predicts that, ``Over time, a sustained reduction in 
     payment updates, based on productivity expectations that are 
     difficult to attain, would cause Medicare payment rates to 
     grow more slowly than, and in a way that was unrelated to, 
     the provider's costs of furnishing services to beneficiaries. 
     Thus, providers for whom Medicare constitutes a substantive 
     portion of their business could find it difficult to remain 
     profitable and might end their participation in the program 
     (possibly jeopardizing access to care for beneficiaries).''.
       (3) The Medicare Payment Advisory Commission (MedPAC) found 
     that 28 percent of seniors currently have difficulty finding 
     a new physician to treat them.
       (4) Medicare geographic payment inequities are well 
     documented and have been extensively studied.
       (5) The Congressional Budget Office states that per capita 
     health care spending varies widely across the United States.
       (6) Low-cost, high-quality States are setting the national 
     standard for Medicare yet they are penalized by the current 
     Medicare reimbursement formula.
       (7) Geographic payment inequities must be resolved for 
     health care reform to be successful and for Medicare to 
     achieve long-term sustainability.
       (8) Rural counties face unique challenges in delivering 
     health care.
       (9) MedPAC finds that every senior currently has the 
     ability to enroll in a Medicare Advantage plan instead of the 
     traditional government program. The Commission predicts that 
     because of Medicare cuts contained in division B, 1 in 5 
     seniors will no longer have this choice and be forced to 
     receive their Medicare benefits from the traditional program.
       (10) OACT predicts that the Medicare cuts contained in 
     division B will reduce seniors' projected enrollment in 
     Medicare Advantage plans by 64 percent.
       (11) MedPAC estimates that, on average, Medicare physician 
     reimbursements are 20 percent lower than the reimbursements 
     physicians receive from private health plans.
       (12) MedPAC predicts that, on average, Medicare hospital 
     reimbursements will be 6.9 percent below the cost of 
     providing care in 2009.

     SEC. 1912. SENIORS PROTECTION AND MEDICARE REGIONAL PAYMENT 
                   EQUITY FUND.

       (a) Establishment.--The Secretary of Health and Human 
     Services (in this section referred to as the ``Secretary'') 
     shall establish under this title a Seniors Protection and 
     Medicare Regional Payment Equity Fund (in this section 
     referred to as the ``Fund'') which shall be available to the 
     Secretary to provide for improvements (described in 
     subsection (b)(1)) under the Medicare program under title 
     XVIII of the Social Security Act.
       (b) Improvements Made by Fund.--
       (1) In general.--The improvements described in this 
     paragraph are the following:
       (A) Correcting payment inequities.--In order to correct 
     inequities in Medicare payment policies that punish high-
     quality, low-cost counties (as defined in paragraph (2)) and 
     to promote high quality, cost effective patient care, by 
     providing additional funding to Medicare providers located in 
     such counties.
       (B) Preserving seniors' choice.--In order to preserve 
     seniors' ability to choose the Medicare health benefits that 
     best meet their needs, by providing additional funding to 
     ensure that every Medicare beneficiary continues to have 
     access to at least 1 Medicare Advantage plan under part C of 
     the Medicare program.
       (C) Access to medically necessary care and treatment.--By 
     providing such additional funding as may be necessary to 
     ensure access by Medicare beneficiaries to medically 
     necessary care and treatment, including care and treatment 
     furnished by physicians, hospitals, and other health care 
     providers under the Medicare program, without wait lines or 
     coverage determinations based solely on the basis of cost.
       (2) High quality, low-cost county defined.--In this 
     subsection, the term ``high quality, low-cost county'' means 
     a county (or equivalent area) in which, as determined by the 
     Secretary--
       (A) the quality of care exceeds the national average; and
       (B) the per beneficiary fee-for-service Medicare costs are 
     substantially lower than the national average.
       (c) Funding.--
       (1) In general.--There shall be available to the Fund--
       (A) $13,500,000,000 for expenditures from the Fund during 
     5-year period beginning with 2010; and
       (B) $40,500,000,000 for expenditures from the Fund during 
     the 5-year period beginning with 2015.

     Such amounts reflect savings in Federal expenditures and 
     increases in Federal revenues estimated to result from the 
     provisions of division E.
       (2) Funding limitation.--Amounts in the Fund shall be 
     available in advance of appropriations but only if the total 
     amount obligated from the Fund does not exceed the amount 
     available to the Fund under paragraph (1). The Secretary may 
     obligate funds from the Fund only if the Secretary determines 
     (and the Chief Actuary of the Centers for Medicare & Medicaid 
     Services and the appropriate budget officer certify) that 
     there are available in the Fund sufficient amounts to cover 
     all such obligations incurred consistent with the previous 
     sentence.
       Add at the end the following (and conform the table of 
     divisions, titles, and subtitles in section 1(b) 
     accordingly):

           DIVISION E--ENACTING REAL MEDICAL LIABILITY REFORM

                     TABLE OF CONTENTS OF DIVISION

Sec. 4101. Encouraging speedy resolution of claims.
Sec. 4102. Compensating patient injury.
Sec. 4103. Maximizing patient recovery.
Sec. 4104. Additional health benefits.
Sec. 4105. Punitive damages.
Sec. 4106. Authorization of payment of future damages to claimants in 
              health care lawsuits.
Sec. 4107. Definitions.
Sec. 4108. Effect on other laws.
Sec. 4109. State flexibility and protection of states' rights.
Sec. 4110. Applicability; effective date.

[[Page 27571]]



     SEC. 4101. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

       The time for the commencement of a health care lawsuit 
     shall be 3 years after the date of manifestation of injury or 
     1 year after the claimant discovers, or through the use of 
     reasonable diligence should have discovered, the injury, 
     whichever occurs first. In no event shall the time for 
     commencement of a health care lawsuit exceed 3 years after 
     the date of manifestation of injury unless tolled for any of 
     the following--
       (1) upon proof of fraud;
       (2) intentional concealment; or
       (3) the presence of a foreign body, which has no 
     therapeutic or diagnostic purpose or effect, in the person of 
     the injured person.

     Actions by a minor shall be commenced within 3 years from the 
     date of the alleged manifestation of injury except that 
     actions by a minor under the full age of 6 years shall be 
     commenced within 3 years of manifestation of injury or prior 
     to the minor's 8th birthday, whichever provides a longer 
     period. Such time limitation shall be tolled for minors for 
     any period during which a parent or guardian and a health 
     care provider or health care organization have committed 
     fraud or collusion in the failure to bring an action on 
     behalf of the injured minor.

     SEC. 4102. COMPENSATING PATIENT INJURY.

       (a) Unlimited Amount of Damages for Actual Economic Losses 
     in Health Care Lawsuits.--In any health care lawsuit, nothing 
     in this division shall limit a claimant's recovery of the 
     full amount of the available economic damages, 
     notwithstanding the limitation in subsection (b).
       (b) Additional Noneconomic Damages.--In any health care 
     lawsuit, the amount of noneconomic damages, if available, may 
     be as much as $250,000, regardless of the number of parties 
     against whom the action is brought or the number of separate 
     claims or actions brought with respect to the same injury.
       (c) No Discount of Award for Noneconomic Damages.--For 
     purposes of applying the limitation in subsection (b), future 
     noneconomic damages shall not be discounted to present value. 
     The jury shall not be informed about the maximum award for 
     noneconomic damages. An award for noneconomic damages in 
     excess of $250,000 shall be reduced either before the entry 
     of judgment, or by amendment of the judgment after entry of 
     judgment, and such reduction shall be made before accounting 
     for any other reduction in damages required by law. If 
     separate awards are rendered for past and future noneconomic 
     damages and the combined awards exceed $250,000, the future 
     noneconomic damages shall be reduced first.
       (d) Fair Share Rule.--In any health care lawsuit, each 
     party shall be liable for that party's several share of any 
     damages only and not for the share of any other person. Each 
     party shall be liable only for the amount of damages 
     allocated to such party in direct proportion to such party's 
     percentage of responsibility. Whenever a judgment of 
     liability is rendered as to any party, a separate judgment 
     shall be rendered against each such party for the amount 
     allocated to such party. For purposes of this section, the 
     trier of fact shall determine the proportion of 
     responsibility of each party for the claimant's harm.

     SEC. 4103. MAXIMIZING PATIENT RECOVERY.

       (a) Court Supervision of Share of Damages Actually Paid to 
     Claimants.--In any health care lawsuit, the court shall 
     supervise the arrangements for payment of damages to protect 
     against conflicts of interest that may have the effect of 
     reducing the amount of damages awarded that are actually paid 
     to claimants. In particular, in any health care lawsuit in 
     which the attorney for a party claims a financial stake in 
     the outcome by virtue of a contingent fee, the court shall 
     have the power to restrict the payment of a claimant's damage 
     recovery to such attorney, and to redirect such damages to 
     the claimant based upon the interests of justice and 
     principles of equity. In no event shall the total of all 
     contingent fees for representing all claimants in a health 
     care lawsuit exceed the following limits:
       (1) 40 percent of the first $50,000 recovered by the 
     claimant(s).
       (2) 33\1/3\ percent of the next $50,000 recovered by the 
     claimant(s).
       (3) 25 percent of the next $500,000 recovered by the 
     claimant(s).
       (4) 15 percent of any amount by which the recovery by the 
     claimant(s) is in excess of $600,000.
       (b) Applicability.--The limitations in this section shall 
     apply whether the recovery is by judgment, settlement, 
     mediation, arbitration, or any other form of alternative 
     dispute resolution. In a health care lawsuit involving a 
     minor or incompetent person, a court retains the authority to 
     authorize or approve a fee that is less than the maximum 
     permitted under this section. The requirement for court 
     supervision in the first two sentences of subsection (a) 
     applies only in civil actions.

     SEC. 4104. ADDITIONAL HEALTH BENEFITS.

       In any health care lawsuit involving injury or wrongful 
     death, any party may introduce evidence of collateral source 
     benefits. If a party elects to introduce such evidence, any 
     opposing party may introduce evidence of any amount paid or 
     contributed or reasonably likely to be paid or contributed in 
     the future by or on behalf of the opposing party to secure 
     the right to such collateral source benefits. No provider of 
     collateral source benefits shall recover any amount against 
     the claimant or receive any lien or credit against the 
     claimant's recovery or be equitably or legally subrogated to 
     the right of the claimant in a health care lawsuit involving 
     injury or wrongful death. This section shall apply to any 
     health care lawsuit that is settled as well as a health care 
     lawsuit that is resolved by a fact finder. This section shall 
     not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section 
     1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security 
     Act.

     SEC. 4105. PUNITIVE DAMAGES.

       (a) In General.--Punitive damages may, if otherwise 
     permitted by applicable State or Federal law, be awarded 
     against any person in a health care lawsuit only if it is 
     proven by clear and convincing evidence that such person 
     acted with malicious intent to injure the claimant, or that 
     such person deliberately failed to avoid unnecessary injury 
     that such person knew the claimant was substantially certain 
     to suffer. In any health care lawsuit where no judgment for 
     compensatory damages is rendered against such person, no 
     punitive damages may be awarded with respect to the claim in 
     such lawsuit. No demand for punitive damages shall be 
     included in a health care lawsuit as initially filed. A court 
     may allow a claimant to file an amended pleading for punitive 
     damages only upon a motion by the claimant and after a 
     finding by the court, upon review of supporting and opposing 
     affidavits or after a hearing, after weighing the evidence, 
     that the claimant has established by a substantial 
     probability that the claimant will prevail on the claim for 
     punitive damages. At the request of any party in a health 
     care lawsuit, the trier of fact shall consider in a separate 
     proceeding--
       (1) whether punitive damages are to be awarded and the 
     amount of such award; and
       (2) the amount of punitive damages following a 
     determination of punitive liability.

     If a separate proceeding is requested, evidence relevant only 
     to the claim for punitive damages, as determined by 
     applicable State law, shall be inadmissible in any proceeding 
     to determine whether compensatory damages are to be awarded.
       (b) Determining Amount of Punitive Damages.--
       (1) Factors considered.--In determining the amount of 
     punitive damages, if awarded, in a health care lawsuit, the 
     trier of fact shall consider only the following--
       (A) the severity of the harm caused by the conduct of such 
     party;
       (B) the duration of the conduct or any concealment of it by 
     such party;
       (C) the profitability of the conduct to such party;
       (D) the number of products sold or medical procedures 
     rendered for compensation, as the case may be, by such party, 
     of the kind causing the harm complained of by the claimant;
       (E) any criminal penalties imposed on such party, as a 
     result of the conduct complained of by the claimant; and
       (F) the amount of any civil fines assessed against such 
     party as a result of the conduct complained of by the 
     claimant.
       (2) Maximum award.--The amount of punitive damages, if 
     awarded, in a health care lawsuit may be as much as $250,000 
     or as much as two times the amount of economic damages 
     awarded, whichever is greater. The jury shall not be informed 
     of this limitation.

     SEC. 4106. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO 
                   CLAIMANTS IN HEALTH CARE LAWSUITS.

       (a) In General.--In any health care lawsuit, if an award of 
     future damages, without reduction to present value, equaling 
     or exceeding $50,000 is made against a party with sufficient 
     insurance or other assets to fund a periodic payment of such 
     a judgment, the court shall, at the request of any party, 
     enter a judgment ordering that the future damages be paid by 
     periodic payments. In any health care lawsuit, the court may 
     be guided by the Uniform Periodic Payment of Judgments Act 
     promulgated by the National Conference of Commissioners on 
     Uniform State Laws.
       (b) Applicability.--This section applies to all actions 
     which have not been first set for trial or retrial before the 
     effective date of this division.

     SEC. 4107. DEFINITIONS.

       In this division:
       (1) Alternative dispute resolution system; adr.--The term 
     ``alternative dispute resolution system'' or ``ADR'' means a 
     system that provides for the resolution of health care 
     lawsuits in a manner other than through a civil action 
     brought in a State or Federal court.
       (2) Claimant.--The term ``claimant'' means any person who 
     brings a health care lawsuit, including a person who asserts 
     or claims a right to legal or equitable contribution, 
     indemnity, or subrogation, arising out of a health care 
     liability claim or action, and any person on whose behalf 
     such a claim is asserted or such an action is brought, 
     whether deceased, incompetent, or a minor.
       (3) Collateral source benefits.--The term ``collateral 
     source benefits'' means any amount paid or reasonably likely 
     to be paid in the future to or on behalf of the claimant, or 
     any service, product, or other benefit provided or reasonably 
     likely to be provided in

[[Page 27572]]

     the future to or on behalf of the claimant, as a result of 
     the injury or wrongful death, pursuant to--
       (A) any State or Federal health, sickness, income-
     disability, accident, or workers' compensation law;
       (B) any health, sickness, income-disability, or accident 
     insurance that provides health benefits or income-disability 
     coverage;
       (C) any contract or agreement of any group, organization, 
     partnership, or corporation to provide, pay for, or reimburse 
     the cost of medical, hospital, dental, or income-disability 
     benefits; and
       (D) any other publicly or privately funded program.
       (4) Compensatory damages.--The term ``compensatory 
     damages'' means objectively verifiable monetary losses 
     incurred as a result of the provision of, use of, or payment 
     for (or failure to provide, use, or pay for) health care 
     services or medical products, such as past and future medical 
     expenses, loss of past and future earnings, cost of obtaining 
     domestic services, loss of employment, and loss of business 
     or employment opportunities, damages for physical and 
     emotional pain, suffering, inconvenience, physical 
     impairment, mental anguish, disfigurement, loss of enjoyment 
     of life, loss of society and companionship, loss of 
     consortium (other than loss of domestic service), hedonic 
     damages, injury to reputation, and all other nonpecuniary 
     losses of any kind or nature. The term ``compensatory 
     damages'' includes economic damages and noneconomic damages, 
     as such terms are defined in this section.
       (5) Contingent fee.--The term ``contingent fee'' includes 
     all compensation to any person or persons which is payable 
     only if a recovery is effected on behalf of one or more 
     claimants.
       (6) Economic damages.--The term ``economic damages'' means 
     objectively verifiable monetary losses incurred as a result 
     of the provision of, use of, or payment for (or failure to 
     provide, use, or pay for) health care services or medical 
     products, such as past and future medical expenses, loss of 
     past and future earnings, cost of obtaining domestic 
     services, loss of employment, and loss of business or 
     employment opportunities.
       (7) Health care lawsuit.--The term ``health care lawsuit'' 
     means any health care liability claim concerning the 
     provision of health care goods or services or any medical 
     product affecting interstate commerce, or any health care 
     liability action concerning the provision of health care 
     goods or services or any medical product affecting interstate 
     commerce, brought in a State or Federal court or pursuant to 
     an alternative dispute resolution system, against a health 
     care provider, a health care organization, or the 
     manufacturer, distributor, supplier, marketer, promoter, or 
     seller of a medical product, regardless of the theory of 
     liability on which the claim is based, or the number of 
     claimants, plaintiffs, defendants, or other parties, or the 
     number of claims or causes of action, in which the claimant 
     alleges a health care liability claim. Such term does not 
     include a claim or action which is based on criminal 
     liability; which seeks civil fines or penalties paid to 
     Federal, State, or local government; or which is grounded in 
     antitrust.
       (8) Health care liability action.--The term ``health care 
     liability action'' means a civil action brought in a State or 
     Federal court or pursuant to an alternative dispute 
     resolution system, against a health care provider, a health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     regardless of the theory of liability on which the claim is 
     based, or the number of plaintiffs, defendants, or other 
     parties, or the number of causes of action, in which the 
     claimant alleges a health care liability claim.
       (9) Health care liability claim.--The term ``health care 
     liability claim'' means a demand by any person, whether or 
     not pursuant to ADR, against a health care provider, health 
     care organization, or the manufacturer, distributor, 
     supplier, marketer, promoter, or seller of a medical product, 
     including, but not limited to, third-party claims, cross-
     claims, counter-claims, or contribution claims, which are 
     based upon the provision of, use of, or payment for (or the 
     failure to provide, use, or pay for) health care services or 
     medical products, regardless of the theory of liability on 
     which the claim is based, or the number of plaintiffs, 
     defendants, or other parties, or the number of causes of 
     action.
       (10) Health care organization.--The term ``health care 
     organization'' means any person or entity which is obligated 
     to provide or pay for health benefits under any health plan, 
     including any person or entity acting under a contract or 
     arrangement with a health care organization to provide or 
     administer any health benefit.
       (11) Health care provider.--The term ``health care 
     provider'' means any person or entity required by State or 
     Federal laws or regulations to be licensed, registered, or 
     certified to provide health care services, and being either 
     so licensed, registered, or certified, or exempted from such 
     requirement by other statute or regulation.
       (12) Health care goods or services.--The term ``health care 
     goods or services'' means any goods or services provided by a 
     health care organization, provider, or by any individual 
     working under the supervision of a health care provider, that 
     relates to the diagnosis, prevention, or treatment of any 
     human disease or impairment, or the assessment or care of the 
     health of human beings.
       (13) Malicious intent to injure.--The term ``malicious 
     intent to injure'' means intentionally causing or attempting 
     to cause physical injury other than providing health care 
     goods or services.
       (14) Medical product.--The term ``medical product'' means a 
     drug, device, or biological product intended for humans, and 
     the terms ``drug'', ``device'', and ``biological product'' 
     have the meanings given such terms in sections 201(g)(1) and 
     201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C. 
     321(g)(1) and (h)) and section 351(a) of the Public Health 
     Service Act (42 U.S.C. 262(a)), respectively, including any 
     component or raw material used therein, but excluding health 
     care services.
       (15) Noneconomic damages.--The term ``noneconomic damages'' 
     means damages for physical and emotional pain, suffering, 
     inconvenience, physical impairment, mental anguish, 
     disfigurement, loss of enjoyment of life, loss of society and 
     companionship, loss of consortium (other than loss of 
     domestic service), hedonic damages, injury to reputation, and 
     all other nonpecuniary losses of any kind or nature.
       (16) Punitive damages.--The term ``punitive damages'' means 
     damages awarded, for the purpose of punishment or deterrence, 
     and not solely for compensatory purposes, against a health 
     care provider, health care organization, or a manufacturer, 
     distributor, or supplier of a medical product. Punitive 
     damages are neither economic nor noneconomic damages.
       (17) Recovery.--The term ``recovery'' means the net sum 
     recovered after deducting any disbursements or costs incurred 
     in connection with prosecution or settlement of the claim, 
     including all costs paid or advanced by any person. Costs of 
     health care incurred by the plaintiff and the attorneys' 
     office overhead costs or charges for legal services are not 
     deductible disbursements or costs for such purpose.
       (18) State.--The term ``State'' means each of the several 
     States, the District of Columbia, the Commonwealth of Puerto 
     Rico, the Virgin Islands, Guam, American Samoa, the Northern 
     Mariana Islands, the Trust Territory of the Pacific Islands, 
     and any other territory or possession of the United States, 
     or any political subdivision thereof.

     SEC. 4108. EFFECT ON OTHER LAWS.

       (a) Vaccine Injury.--
       (1) To the extent that title XXI of the Public Health 
     Service Act establishes a Federal rule of law applicable to a 
     civil action brought for a vaccine-related injury or death--
       (A) this division does not affect the application of the 
     rule of law to such an action; and
       (B) any rule of law prescribed by this division in conflict 
     with a rule of law of such title XXI shall not apply to such 
     action.
       (2) If there is an aspect of a civil action brought for a 
     vaccine-related injury or death to which a Federal rule of 
     law under title XXI of the Public Health Service Act does not 
     apply, then this division or otherwise applicable law (as 
     determined under this division) will apply to such aspect of 
     such action.
       (b) Other Federal Law.--Except as provided in this section, 
     nothing in this division shall be deemed to affect any 
     defense available to a defendant in a health care lawsuit or 
     action under any other provision of Federal law.

     SEC. 4109. STATE FLEXIBILITY AND PROTECTION OF STATES' 
                   RIGHTS.

       (a) Health Care Lawsuits.--The provisions governing health 
     care lawsuits set forth in this division preempt, subject to 
     subsections (b) and (c), State law to the extent that State 
     law prevents the application of any provisions of law 
     established by or under this division. The provisions 
     governing health care lawsuits set forth in this division 
     supersede chapter 171 of title 28, United States Code, to the 
     extent that such chapter--
       (1) provides for a greater amount of damages or contingent 
     fees, a longer period in which a health care lawsuit may be 
     commenced, or a reduced applicability or scope of periodic 
     payment of future damages, than provided in this division; or
       (2) prohibits the introduction of evidence regarding 
     collateral source benefits, or mandates or permits 
     subrogation or a lien on collateral source benefits.
       (b) Protection of States' Rights and Other Laws.--(1) Any 
     issue that is not governed by any provision of law 
     established by or under this division (including State 
     standards of negligence) shall be governed by otherwise 
     applicable State or Federal law.
       (2) This division shall not preempt or supersede any State 
     or Federal law that imposes greater procedural or substantive 
     protections for health care providers and health care 
     organizations from liability, loss, or damages than those 
     provided by this division or create a cause of action.
       (c) State Flexibility.--No provision of this division shall 
     be construed to preempt--

[[Page 27573]]

       (1) any State law (whether effective before, on, or after 
     the date of the enactment of this Act) that specifies a 
     particular monetary amount of compensatory or punitive 
     damages (or the total amount of damages) that may be awarded 
     in a health care lawsuit, regardless of whether such monetary 
     amount is greater or lesser than is provided for under this 
     division, notwithstanding section 4102(a); or
       (2) any defense available to a party in a health care 
     lawsuit under any other provision of State or Federal law.

     SEC. 4110. APPLICABILITY; EFFECTIVE DATE.

       This division shall apply to any health care lawsuit 
     brought in a Federal or State court, or subject to an 
     alternative dispute resolution system, that is initiated on 
     or after the date of the enactment of this Act, except that 
     any health care lawsuit arising from an injury occurring 
     prior to the date of the enactment of this Act shall be 
     governed by the applicable statute of limitations provisions 
     in effect at the time the injury occurred.

  The SPEAKER pro tempore. Pursuant to the rule, the gentleman from 
Virginia is recognized for 5 minutes in support of the motion.

                              {time}  2230

  Mr. CANTOR. Mr. Speaker, any physician in America will tell you that 
the simplest way to reduce health care costs is to enact real medical 
liability reform. The fear of being sued by opportunistic trial lawyers 
is pervasive in the practice of medicine. Our system wastes billions on 
defensive medicine that should be going to patient care. That's why 
real medical liability reform is needed. In fact, CBO estimates that as 
much as $54 billion can be saved by the Federal Government alone. It is 
totally unacceptable that this money is being spent in the courtroom 
instead of the operating room.
  At the same time, the majority has promised the American people that 
their health care bill will lower costs, yet the bill before us today, 
Mr. Speaker, contains no medical liability reforms. And why not? The 
truth comes from one of the Democrats' own, no less than former DNC 
Chair and physician Howard Dean, who said last August, The reason that 
tort reform is not in the bill is because the people that wrote it did 
not want to take on the trial lawyers in addition to everybody else 
they were taking on, and that is the plain and simple truth.
  Mr. Speaker, the Republican motion to recommit adds real meaningful 
medical liability and reform and uses its $54 billion in savings to 
create a fund that will protect seniors, especially those in rural 
areas, from the steep cuts to Medicare in the Democrats' reform 
package. It gives Members the chance to prioritize the health of our 
Nation's seniors instead of lining the bank accounts of trial lawyers. 
It's time to get trial lawyers out of the clinics and the operating 
rooms and leave patient care to the people trained to handle it best--
our doctors.
  Mr. Speaker, to talk about this further, I now yield to the 
gentlewoman from Florida, Congresswoman Brown-Waite.
  Ms. GINNY BROWN-WAITE of Florida. Betty, a constituent of mine, 
recently told me that if it weren't for Medicare Advantage, she would 
be dead. You see, Medicare Advantage covers catastrophic costs 
traditional Medicare does not. The bill before us today seeks to 
eliminate that coverage for millions of seniors, but you have a chance 
to make it right here, ladies and gentlemen.
  The choice on the motion is simple. You can put your seniors first or 
your trial lawyer contributors. A Member can vote to open up the 
coffers of the U.S. Treasury to trial lawyers or restore some of the 
cuts our seniors will suffer under the Pelosi bill and ObamaCare. 
Remember, this bill creates 111 new bureaucracies and entitlements, but 
the only one it cuts, ladies and gentlemen, the only one it cuts is 
Medicare. It's always been my position that any money cut from Medicare 
should be used to save Medicare, not to bail out the trial attorneys.
  Democrats have denied seniors the protection they promised. They cut 
Medicare to create new benefits for the young, healthy, and the 
wealthy. We know where the Democrat leadership stands on this issue. 
The Speaker put her trial lawyer cash cows ahead of our seniors. AARP 
put their profits ahead of our seniors.
  With this motion, you have a chance to restore some of our cuts. No 
excuses about this amendment killing the bill can be made. No word 
games can get you out of this. This has to be a vote for the seniors of 
America. Please remember your constituents will be watching.
  Mr. CANTOR. Mr. Speaker, I now yield to the gentleman from Washington 
(Mr. Reichert).
  Mr. REICHERT. Thank you.
  This motion was and will protect seniors from drastic cuts to 
Medicare and stop expensive lawsuits that increase the costs of health 
care for every American. We've heard, If you like it, you can keep it, 
but the bill before us is a direct assault on America's seniors, 
cutting $500 billion from Medicare.
  Under this bill, one out of every five seniors will lose the Medicare 
health plan they chose. Because of regional payment disparities in many 
parts of this country, Medicare Advantage plans are the only way 
seniors can receive needed care. It's the only way that seniors can 
choose their doctors, and it's the only way that seniors can choose the 
preventive treatment they need.
  This motion is about choice. It's about living in a free country. 
It's about having freedom. Mr. Speaker, this commonsense motion will 
protect seniors' health care, lower health care costs, and preserve 
freedom.
  Mr. HOYER. Mr. Speaker, I rise in opposition to the motion to 
recommit.
  The SPEAKER pro tempore. The gentleman from Maryland is recognized 
for 5 minutes.
  Mr. HOYER. Mr. Speaker, I yield to the gentleman from Iowa (Mr. 
Braley).
  Mr. BRALEY of Iowa. Mr. Speaker, during this entire health care 
debate, we've heard a lot from our friends on the other side of the 
aisle about something called medical liability reform, but all day as 
they've been talking about this point, you have not heard one word 
about patient safety. If you want to talk about real meaningful health 
care reform, it's important to talk about the most critical aspect of 
true, meaningful health care reform--standing up for patients. Who will 
speak for the patients?
  Mr. Speaker, we know who will speak for the patients. We have the 
reports from the highly respected nonpartisan Institute of Medicine on 
patient safety. The first one is on patient safety, Achieving a New 
Standard for Care. The second one, Preventing Medication Errors, and To 
Err Is Human: Building a Safer Health System.
  What did the Institute of Medicine tell us about the state of patient 
safety? They told us that the most significant way to reduce the costs 
of medical malpractice is to emphasize patient safety by reducing the 
number of preventable medical errors. They also told us that's the only 
way we're going to bring about meaningful health care reform. They also 
told us that medical errors kill as many as 98,000 Americans every 
year; and that, if it were ranked by the Centers for Disease Controls, 
would be the sixth leading cause of deaths in America.

                              {time}  2240

  They also told us that every year there are 15 million incidents of 
medical harm in this country and that patient safety is 
indistinguishable from the delivery of medical care. That's why they 
aren't telling you about what the Institutes of Medicine reported the 
cost of medical errors is in this country.
  They reported in their studies that every year medical errors add $17 
billion to $28 billion of cost, most of it in additional medical care 
that we end up paying for as consumers of health care. When you 
multiply that over the 10 years of this bill, that means it's costing 
us $170 billion to $280 billion if we continue to ignore this problem. 
That's why Democrats and the Institutes of Medicine are standing up for 
patients, and that's why you should reject this motion to recommit.
  You hear our friends talk about what happened in California in 1976 
when they put a $250,000 cap on payments for quality-of-life damages. 
What they don't tell you is that the value of that cap today in 2009 is 
$64,000, and if you

[[Page 27574]]

adjust that cap at the same rate of medical inflation, it would be 
worth $1.9 million. That's what's wrong.
  Mr. HOYER. I thank the gentleman for his comments.
  My colleagues, I ask you to reject this amendment. Our colleagues on 
the other side of the aisle demanded 72 hours' notice for the bill and 
they've gotten 4 or 5 months' notice. They gave us 72 seconds to 
consider this amendment.
  This amendment deals with some very complicated subjects; and it 
provides, of course, as we are not surprised that it would, for 
substantial billions of dollars back to the insurance companies. That's 
what their objective is. And, yes, they say something about equity of 
distribution of money. No study.
  We set up a very careful study to make sure that the people's money 
is distributed to the States in an equitable, fair, effective fashion. 
That is why we ought to reject this amendment for which we received no 
notice, no consideration, no discussion in the public. The Republicans 
have been outraged about that.
  I ask our party, I ask each one of us, to reject this motion to 
recommit and pass this bill.
  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 noes appeared to have it.


                             Recorded Vote

  Mr. CANTOR. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The vote was taken by electronic device, and there were--ayes 187, 
noes 247, not voting 0, as follows:

                             [Roll No. 886]

                               AYES--187

     Aderholt
     Akin
     Alexander
     Austria
     Bachmann
     Bachus
     Barrett (SC)
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boustany
     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Cao
     Capito
     Cardoza
     Carter
     Cassidy
     Castle
     Chaffetz
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Costa
     Crenshaw
     Cuellar
     Culberson
     Davis (KY)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Ehlers
     Ellsworth
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Gordon (TN)
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Hoekstra
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kline (MN)
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McKeon
     McMorris Rodgers
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Minnick
     Moran (KS)
     Murphy (NY)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Olson
     Paulsen
     Pence
     Petri
     Pitts
     Platts
     Poe (TX)
     Pomeroy
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuster
     Simpson
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Sullivan
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)

                               NOES--247

     Abercrombie
     Ackerman
     Adler (NJ)
     Altmire
     Andrews
     Arcuri
     Baca
     Baird
     Baldwin
     Barrow
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boccieri
     Boswell
     Boucher
     Boyd
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Capps
     Capuano
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chandler
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costello
     Courtney
     Crowley
     Cummings
     Dahlkemper
     Davis (AL)
     Davis (CA)
     Davis (IL)
     Davis (TN)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Duncan
     Edwards (MD)
     Edwards (TX)
     Ellison
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Herseth Sandlin
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holden
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson (IL)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy
     Kind
     Kirkpatrick (AZ)
     Kissell
     Klein (FL)
     Kosmas
     Kratovil
     Kucinich
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Lipinski
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (CO)
     Markey (MA)
     Marshall
     Massa
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McIntyre
     McMahon
     McNerney
     Meek (FL)
     Meeks (NY)
     Melancon
     Michaud
     Miller (NC)
     Miller, George
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Nye
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Paul
     Payne
     Perlmutter
     Perriello
     Peters
     Peterson
     Pingree (ME)
     Polis (CO)
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Ross
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Shuler
     Sires
     Skelton
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Tanner
     Taylor
     Teague
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                              {time}  2259

  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.


                             Recorded Vote

  Mr. BURTON of Indiana. Mr. Speaker, I demand a recorded vote.
  A recorded vote was ordered.
  The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, this 15-
minute vote on passage of the bill will be followed by a 5-minute vote 
on the motion to suspend the rules on House Resolution 895.
  The vote was taken by electronic device, and there were--ayes 220, 
noes 215, not voting 0, as follows:

                             [Roll No. 887]

                               AYES--220

     Abercrombie
     Ackerman
     Andrews
     Arcuri
     Baca
     Baldwin
     Bean
     Becerra
     Berkley
     Berman
     Berry
     Bishop (GA)
     Bishop (NY)
     Blumenauer
     Boswell
     Brady (PA)
     Braley (IA)
     Brown, Corrine
     Butterfield
     Cao
     Capps
     Capuano
     Cardoza
     Carnahan
     Carney
     Carson (IN)
     Castor (FL)
     Chu
     Clarke
     Clay
     Cleaver
     Clyburn
     Cohen
     Connolly (VA)
     Conyers
     Cooper
     Costa
     Costello
     Courtney
     Crowley
     Cuellar
     Cummings
     Dahlkemper
     Davis (CA)
     Davis (IL)
     DeFazio
     DeGette
     Delahunt
     DeLauro
     Dicks
     Dingell
     Doggett
     Donnelly (IN)
     Doyle
     Driehaus
     Edwards (MD)
     Ellison
     Ellsworth
     Engel
     Eshoo
     Etheridge
     Farr
     Fattah
     Filner
     Foster
     Frank (MA)
     Fudge
     Garamendi
     Giffords
     Gonzalez
     Grayson
     Green, Al
     Green, Gene
     Grijalva
     Gutierrez
     Hall (NY)
     Halvorson
     Hare
     Harman
     Hastings (FL)
     Heinrich
     Higgins
     Hill
     Himes
     Hinchey
     Hinojosa
     Hirono
     Hodes
     Holt
     Honda
     Hoyer
     Inslee
     Israel
     Jackson (IL)
     Jackson-Lee (TX)
     Johnson (GA)
     Johnson, E. B.
     Kagen
     Kanjorski
     Kaptur
     Kennedy
     Kildee
     Kilpatrick (MI)
     Kilroy

[[Page 27575]]


     Kind
     Kirkpatrick (AZ)
     Klein (FL)
     Langevin
     Larsen (WA)
     Larson (CT)
     Lee (CA)
     Levin
     Lewis (GA)
     Lipinski
     Loebsack
     Lofgren, Zoe
     Lowey
     Lujan
     Lynch
     Maffei
     Maloney
     Markey (MA)
     Matsui
     McCarthy (NY)
     McCollum
     McDermott
     McGovern
     McNerney
     Meek (FL)
     Meeks (NY)
     Michaud
     Miller (NC)
     Miller, George
     Mitchell
     Mollohan
     Moore (KS)
     Moore (WI)
     Moran (VA)
     Murphy (CT)
     Murphy, Patrick
     Murtha
     Nadler (NY)
     Napolitano
     Neal (MA)
     Oberstar
     Obey
     Olver
     Ortiz
     Owens
     Pallone
     Pascrell
     Pastor (AZ)
     Payne
     Pelosi
     Perlmutter
     Perriello
     Peters
     Pingree (ME)
     Polis (CO)
     Pomeroy
     Price (NC)
     Quigley
     Rahall
     Rangel
     Reyes
     Richardson
     Rodriguez
     Rothman (NJ)
     Roybal-Allard
     Ruppersberger
     Rush
     Ryan (OH)
     Salazar
     Sanchez, Linda T.
     Sanchez, Loretta
     Sarbanes
     Schakowsky
     Schauer
     Schiff
     Schrader
     Schwartz
     Scott (GA)
     Scott (VA)
     Serrano
     Sestak
     Shea-Porter
     Sherman
     Sires
     Slaughter
     Smith (WA)
     Snyder
     Space
     Speier
     Spratt
     Stark
     Stupak
     Sutton
     Thompson (CA)
     Thompson (MS)
     Tierney
     Titus
     Tonko
     Towns
     Tsongas
     Van Hollen
     Velazquez
     Visclosky
     Walz
     Wasserman Schultz
     Waters
     Watson
     Watt
     Waxman
     Weiner
     Welch
     Wexler
     Wilson (OH)
     Woolsey
     Wu
     Yarmuth

                               NOES--215

     Aderholt
     Adler (NJ)
     Akin
     Alexander
     Altmire
     Austria
     Bachmann
     Bachus
     Baird
     Barrett (SC)
     Barrow
     Bartlett
     Barton (TX)
     Biggert
     Bilbray
     Bilirakis
     Bishop (UT)
     Blackburn
     Blunt
     Boccieri
     Boehner
     Bonner
     Bono Mack
     Boozman
     Boren
     Boucher
     Boustany
     Boyd
     Brady (TX)
     Bright
     Broun (GA)
     Brown (SC)
     Brown-Waite, Ginny
     Buchanan
     Burgess
     Burton (IN)
     Buyer
     Calvert
     Camp
     Campbell
     Cantor
     Capito
     Carter
     Cassidy
     Castle
     Chaffetz
     Chandler
     Childers
     Coble
     Coffman (CO)
     Cole
     Conaway
     Crenshaw
     Culberson
     Davis (AL)
     Davis (KY)
     Davis (TN)
     Deal (GA)
     Dent
     Diaz-Balart, L.
     Diaz-Balart, M.
     Dreier
     Duncan
     Edwards (TX)
     Ehlers
     Emerson
     Fallin
     Flake
     Fleming
     Forbes
     Fortenberry
     Foxx
     Franks (AZ)
     Frelinghuysen
     Gallegly
     Garrett (NJ)
     Gerlach
     Gingrey (GA)
     Gohmert
     Goodlatte
     Gordon (TN)
     Granger
     Graves
     Griffith
     Guthrie
     Hall (TX)
     Harper
     Hastings (WA)
     Heller
     Hensarling
     Herger
     Herseth Sandlin
     Hoekstra
     Holden
     Hunter
     Inglis
     Issa
     Jenkins
     Johnson (IL)
     Johnson, Sam
     Jones
     Jordan (OH)
     King (IA)
     King (NY)
     Kingston
     Kirk
     Kissell
     Kline (MN)
     Kosmas
     Kratovil
     Kucinich
     Lamborn
     Lance
     Latham
     LaTourette
     Latta
     Lee (NY)
     Lewis (CA)
     Linder
     LoBiondo
     Lucas
     Luetkemeyer
     Lummis
     Lungren, Daniel E.
     Mack
     Manzullo
     Marchant
     Markey (CO)
     Marshall
     Massa
     Matheson
     McCarthy (CA)
     McCaul
     McClintock
     McCotter
     McHenry
     McIntyre
     McKeon
     McMahon
     McMorris Rodgers
     Melancon
     Mica
     Miller (FL)
     Miller (MI)
     Miller, Gary
     Minnick
     Moran (KS)
     Murphy (NY)
     Murphy, Tim
     Myrick
     Neugebauer
     Nunes
     Nye
     Olson
     Paul
     Paulsen
     Pence
     Peterson
     Petri
     Pitts
     Platts
     Poe (TX)
     Posey
     Price (GA)
     Putnam
     Radanovich
     Rehberg
     Reichert
     Roe (TN)
     Rogers (AL)
     Rogers (KY)
     Rogers (MI)
     Rohrabacher
     Rooney
     Ros-Lehtinen
     Roskam
     Ross
     Royce
     Ryan (WI)
     Scalise
     Schmidt
     Schock
     Sensenbrenner
     Sessions
     Shadegg
     Shimkus
     Shuler
     Shuster
     Simpson
     Skelton
     Smith (NE)
     Smith (NJ)
     Smith (TX)
     Souder
     Stearns
     Sullivan
     Tanner
     Taylor
     Teague
     Terry
     Thompson (PA)
     Thornberry
     Tiahrt
     Tiberi
     Turner
     Upton
     Walden
     Wamp
     Westmoreland
     Whitfield
     Wilson (SC)
     Wittman
     Wolf
     Young (AK)
     Young (FL)


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore (during the vote). The Chair will remind all 
persons in the gallery that they are here as guests of the House and 
that any manifestation of approval or disapproval of proceedings or 
other audible conversation is in violation of the rules of the House.


                      Announcement by the Speaker

  The SPEAKER (during the vote). There are 2 minutes remaining in the 
vote.

                              {time}  2316

  So the bill was passed.
  The result of the vote was announced as above recorded.
  A motion to reconsider was laid on the table.

                          ____________________