[Senate Report 104-346]
[From the U.S. Government Publishing Office]



                                                       Calendar No. 555
104th Congress                                                   Report
                                 SENATE

 2d Session                                                     104-346
_______________________________________________________________________


 
    INDIAN HEALTH CARE IMPROVEMENT TECHNICAL CORRECTIONS ACT OF 1996

                                _______
                                

                 July 31, 1996.--Ordered to be printed

_______________________________________________________________________


    Mr. McCain, from the Committee on Indian Affairs, submitted the 
                               following

                              R E P O R T

                         [To accompany S. 1869]

    The Committee on Indian Affairs, to which was referred the 
bill (S. 1869) the Indian Health Care Improvement Technical 
Corrections Act of 1996, having considered the same, reports 
favorably thereon without amendment and recommends that the 
bill do pass.

                                Purposes

    The purpose of S. 1869 is to amend the Indian Health Care 
Improvement Act (25 U.S.C. Sec. 1601 et seq.) by making 
technical corrections to certain provisions of the Act and 
reauthorizing several Indian health care demonstration 
programs.

          Background on the Indian Health Care Improvement Act

    Through numerous treaties, statutes, regulations, and cased 
law, the United States has established a fundamental trust 
obligation to ensure that comprehensive health care is provided 
to American Indians and Alaska Natives. The Congress enacted 
the Indian Health Care Improvement Act in 1976 in an effort to 
raise the health status of American Indians and Alaska Natives 
to a level comparable to the national population. While the 
health status of Indian people has generally improved since its 
enactment, it still lags behind far behind any other segment of 
the American population. Health crises in every possible 
problem area continue to afflict many reservation communities 
at alarming rates. The mortality rate for diabetes exceeds the 
national average by 139 percent. American Indians are four 
times more likely to die from alcoholism than other Americans. 
The incidence rate for Fetal Alcohol Syndrome is six times the 
national average. The mortality rate for tuberculosis among 
Native Americans exceeds the national average by 400 percent.
    In 1992, the Congress amended the Indian Health Care 
Improvement Act to set out 59 health status objectives to 
improve the health status of American Indians and Alaska 
Natives by the year 2000. These health status objectives were 
intended to measure improvements in the health status of 
American Indians and Alaska Natives. The objectives were 
derived from the report of the U.S. Department of Health and 
Human Services, entitled ``Healthy People 2000: National Health 
Promotion and Disease Prevention Objectives.'' In the Indian 
Health Amendments of 1992, the Congress extended the 
authorizations of most of the programs administered by the 
Indian Health Service (IHS) through the year 2000, at which 
time the IHS is required to report its progress to the Congress 
in meeting these 59 health status objectives.

 S. 1869, The Indian Health Care Improvement Technical Corrections Act 
                                of 1996

    S. 1869 makes technical amendments to certain provisions of 
the Indian Health Care Improvement Act (IHCIA) and reauthorizes 
several Indian health care demonstration programs through the 
year 2000.
    S. 1869 will clarify certain provisions in order to allow 
greater flexibility to the IHS in administering IHS 
scholarships and programs. The bill modifies the definition of 
Health Profession in Section 4(n) to include ``allopathic 
medicine'' in order to provide more flexibility to the IHS in 
awarding scholarship assistance to individuals enrolled in 
health degree professions. Prior to the 1992 amendments, 
individuals studying disciplines such as allopathic medicine 
were eligible to receive IHS assistance. Because the 1992 
Amendments omitted this reference, many individuals were denied 
eligibility for scholarship assistance. These amendments would 
restore their eligibility for scholarship funds and fulfill the 
Act's intent.
    The bill also clarifies certain provisions under Section 
104(b), the Indian Health Professions Scholarship, to clarify 
the authority of the Secretary of the Department of Health and 
Human Services to waive or defer service or payment obligations 
of Indian health professionals under specified circumstances. 
Many requirements for a degree in the health professions 
include an internship, residency, or other advanced clinical 
program. The bill would clarify the authority of the Secretary 
to defer a scholarship recipient's service or repayment 
obligation until the recipient has completed his or her 
education program.
    The bill also amends Section 206, regarding reimbursement 
from certain third parties for the costs of health services, to 
clarify the notice provisions for individuals in collection 
actions brought by the IHS or tribal health care provider. It 
also clarifies what costs are recoverable in such an action and 
that the IHS and tribal provider shall have the right to 
recover against an insurance company or employee benefit plan.
    In addition, the bill extends the authorization for four 
health care demonstration projects and one grant program 
established as model programs under the Act through the year 
2000. The program authorizations for these programs are due to 
expire.
    The California Contract Health Services Demonstration 
Program authorizes the California Rural Indian Health Board to 
act as a contract care intermediary to improve the 
accessibility of health services to California Indians. The 
project is intended to cover the high-cost contract care cases 
over $1,000 and up to the threshold participation level of the 
Catastrophic Health Emergency Fund. The program has 
successfully enabled tribal programs to provide in-patient 
services and prevent high-cost cases from devastating many 
small tribal health programs in California. Around 41 percent 
of the California tribes participate in this program.
    The Medicare/Medicaid Demonstration Program allows four 
tribal health contract operators to directly bill and collect 
Medicare/Medicaid payments rather than operate through the 
current system of channeling payments through the IHS. The four 
participating Indian tribes include Mississippi Band of Choctaw 
Indians, Bristol Bay Area Health Corporation of Alaska, Choctaw 
Tribe of Oklahoma and South East Alaska Regional Health 
Consortium. The Medicare/Medicaid Demonstration Program has 
been a highly successful program for the participating tribes 
and the IHS, who have reported significantly increased 
collections for Medicare/Medicaid services and greater 
efficiency in the billing/payments process.
    The bill expands the Medicare/Medicaid Demonstration 
Program from four participants to no more than twelve 
participants. The Committee intends that in determining the 
number of eligible participants for this program, all of the 
co-signers and signatory tribes to the Alaska Tribal Health 
Compact between certain Alaska Native tribes and the United 
States of America shall be deemed one participant. This is 
consistent with Title III of Public Law 93-638, as amended, 
which authorized this compact.
    The Home and Community Based Care Demonstration Program 
authorizes Indian tribes to enter into contracts to establish 
demonstration projects for the delivery of home and community 
based services to functionally-disabled Indians. The Substance 
Abuse Counselor Education Demonstration Project authorizes the 
IHS to enter into contracts with, or make grants to, colleges, 
universities and tribally-controlled community colleges to 
develop educational curricula for substance abuse counseling. 
Although funding has not been provided to implement this 
project, the IHS has taken steps to enhance counselor 
certification efforts, including providing training at 
tribally-controlled Indian community colleges.
    The Gallup Alcohol and Substance Abuse Treatment Program 
has funded residential treatment for alcohol and substance 
abuse at the Navajo Adult Rehabilitation Demonstration Project. 
The grant program has also funded a protective custody program 
for alcohol abuse offenders at the Gallup Crisis Center. These 
programs are unique to the Navajo Nation area and provide 
valuable services as a community-based outpatient program.

                          Legislative History

    S. 1869 was introduced by Senator McCain, for himself and 
Senators Kassebaum, Murkowski, Stevens and Simon on June 13, 
1996 and was referred to the Committee on Indian Affairs.

            Committee Recommendation and Tabulation of Vote

    In an open business session on July 18, 1996, the Committee 
on Indian Affairs ordered the bill reported without amendment 
with the recommendation that the Senate do pass the bill as 
reported.

                      Section-by-Section Analysis

    Section 1(a) sets forth the short title of the Act.
    Section 1(b) provides that wherever a section or other 
provision is amended or repealed in this Act, such amendment 
shall be considered made to the referenced section or provision 
of the Indian Health Care Improvement Act (25 U.S.C. 1601 et 
seq.).
    Section 2(a) amends Section 4(n) of the Indian Health Care 
Improvement Act to modify the definition of ``Health 
Profession'' to specify that ``allopathic medicine'' shall be 
added as an eligible degree program for individuals who qualify 
for scholarships and loan repayment programs. This section also 
modifies the definition by striking the current language of 
``and allied health professions'' and inserting ``an allied 
health profession, or any other health profession'' to allow 
the IHS additional flexibility to determine eligibility for 
scholarships and loan repayments for individuals enrolled in 
health professions not specified under this section.
    Section 2(b) amends Section 104(b) of the Indian Health 
Care Improvement Act to add a new provision that clarifies that 
an individual serving in an academic setting that is funded 
under sections 102, 112, or 114 of the Act who is responsible 
for the recruitment and training of Indian Health Professionals 
shall be considered to be meeting their service obligations 
under section 338A of the Public Health Service Act. This 
provision will allow an individual to meet their service 
obligation to the IHS by working at a university or other 
academic setting which is responsible for recruiting and 
training American Indians in the health professions. This is 
also intended to clarify that the Secretary may defer an 
individual's service obligation during the term of an 
internship, residency or other advanced clinical program. 
Section 104(b) is further amended by adding new subsections to 
address unique circumstances under which the Secretary is 
authorized to waive or suspend service or payment obligations 
due to death or the Secretary's determination that it would 
cause extreme hardship or that to enforce such a requirement 
would be unconscionable. An additional subsection is added to 
clarify the terms under which an individual's payment 
obligation may be discharged in a bankruptcy proceeding.
    Section 2(c) amends Section 206 of the Indian Health Care 
Improvement Act to clarify the notice provisions for 
individuals in collection actions for services provided by IHS 
or tribal health facilities and recoverable costs in such a 
collection action and the right of the United States and Indian 
tribes to recover against an insurance company or employee 
benefit plan.
    Section 2(d) amends Section 211(g) of the Indian Health 
Care Improvement Act to extend the authorization for the 
California Contract Health Services Demonstration Program until 
the year 2000.
    Section 2(e) amends Section 405(c) of the Indian Health 
Care Improvement Act to provide that applicants for the 
Medicare and Medicaid Demonstration Program must be accredited 
by the Joint Commission on Accreditation of Hospitals within 
one year of submission of an application. Section 405(c) is 
amended to increase the number of eligible tribal health 
facilities from four to twelve. The authorization for the 
Medicare and Medicaid Demonstration Program is extended through 
the fiscal year 2000.
    Section 2(f) amends Section 706(d) of the Indian Health 
Care Improvement Act to strike out 706(d) in its entirety and 
add a new subsection that will extend the authorization for the 
Gallup Alcohol and Substance Abuse Treatment Center through the 
fiscal year 2000.
    Section 2(g) amends Section 711(h) of the Indian Health 
Care Improvement Act to extend the authorization for the 
Substance Abuse Counselor Education Demonstration Program 
through the fiscal year 2000.
    Section 2(h) amends Section 821(I) of the Indian Health 
Care Improvement Act to extend the authorization for the Home 
and Community-Based Care Demonstration Program through the 
fiscal year 2000.

                   Cost and Budgetary Considerations

    The cost estimate for S. 1869 as calculated by the 
Congressional Budget Office is set forth below:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, July 26, 1996.
Hon. John McCain,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for S. 1869, the Indian 
Health Care Improvement Technical Corrections Act of 1996.
    Enactment of S. 1869 would not affect direct spending or 
receipts. Therefore, pay-as-you-go procedures would not apply 
to the bill.
    If you wish further details on this estimate, we will be 
pleased to provide them.
            Sincerely,
                                         June E. O'Neill, Director.

               congressional budget office cost estimate

    1. Bill number: S. 1869.
    2. Bill title: The Indian Health Care Improvement Technical 
Corrections Act of 1996.
    3. Bill status: As ordered reported by the Senate Committee 
on Indian Affairs on July 18, 1996.
    4. Bill purpose: S. 1869 would reauthorize five Indian 
Health Service (IHS) programs and would make amendments to the 
Indian Health Professions Scholarship program. Also, for the 
purposes of the Indian Health Care Improvement Act, the bill 
would expand the definition of health professions.
    5. Estimated cost to the Federal Government: Assuming 
appropriation of the necessary funds, CBO estimates that the 
federal government would spend $25 million over the fiscal year 
1997-2002 period to implement the provisions of S. 1869. The 
following table summarizes the estimated authorizations and 
outlays that would result from S. 1869 under two different sets 
of assumptions. The first set of assumptions adjusts the 
estimated amounts for projected inflation after 1996. The 
second set of assumptions makes no allowance for projected 
inflation.

                                    [By fiscal year, in millions of dollars]                                    
----------------------------------------------------------------------------------------------------------------
                                                              1997     1998     1999     2000     2001     2002 
----------------------------------------------------------------------------------------------------------------
                                         WITH ADJUSTMENTS FOR INFLATION                                         
                                                                                                                
Authorizations of appropriations under current law:                                                             
    Estimated authorization...............................    (\1\)  .......  .......  .......  .......  .......
    Estimated outlays.....................................    (\1\)    (\1\)    (\1\)  .......  .......  .......
Proposed changes:                                                                                               
    Estimated authorization...............................        6        6        6        7  .......  .......
    Estimated outlays.....................................        5        6        6        7        2    (\1\)
Authorizations of appropriations under proposal:                                                                
    Estimated authorization...............................        6        6        6        7  .......  .......
    Estimated outlays.....................................        6        6        6        7        2    (\1\)
                                                                                                                
                                        WITHOUT ADJUSTMENTS FOR INFLATION                                       
                                                                                                                
Authorization of appropriations under current law:                                                              
    Estimated authorization...............................    (\1\)  .......  .......  .......  .......  .......
    Estimated outlays.....................................    (\1\)    (\1\)    (\1\)  .......  .......  .......
Proposed changes:                                                                                               
    Estimated authorization...............................        6        6        6        6  .......  .......
    Estimated outlays.....................................        5        6        6        6        1    (\1\)
Authorizations of appropriations under proposal:                                                                
    Estimated authorization...............................        6        6        6        6  .......  .......
    Estimated outlays.....................................        5        6        6        6        1   (\1\) 
----------------------------------------------------------------------------------------------------------------
\1\ Less than $500,000.                                                                                         

    The costs of this bill fall within budget function 550.
    6. Basis of the estimate: S. 1869 would reauthorize five 
IHS programs through fiscal year 2000. Reauthorization of the 
California Contract Health Services Demonstration program would 
cost approximately $1 million through fiscal year 2000. This 
program assesses the effect of the use of contract care 
intermediaries on California Indians' access to medical 
services. Under this demonstration program, the federal 
government reimburses the California Rural Indian Health Board 
for the provision of high-cost contract care that does not meet 
the threshold cost requirement for coverage under the 
Catastrophic Health Emergency Funds.
    The Medicare and Medicaid Direct Billing Demonstration 
Program would be reauthorized under S. 1869. This program 
permits four participating facilities to bill directly, and 
receive reimbursements from, third-party payers for services 
rendered. These entities also entitled to the Medicare and 
Medicaid reimbursement rates that the IHS has negotiated with 
the Health Care Financing Administration. Qualifying 
participants are hospitals or clinics operating under the 
Indian Self-Determination Act by tribes, tribal organizations 
or Alaska Native health organizations. Facilities that do not 
participate in this program can operate as Federally-Qualified 
Health Centers (FQHCs) or can choose to file claims through the 
IHS. Because it enables participants to bill directly for 
services rendered, rather than working through the IHS, the 
demonstration program may reduce IHS administrative costs 
slightly.
    The proposal would also reauthorize two substance abuse 
grant programs. Reauthorization of the Gallup Alcohol and 
Substance Abuse Treatment Center grant program would require 
$1.24 million in appropriations over the 1997-2000 period. This 
program gives grants to the Navajo Nation for residential 
alcohol and substance abuse treatment for adults and 
adolescents. The Substance Abuse Counselor Education 
Demonstration Program would also be reauthorized at a cost of 
$1 million over the 1997-2000 period. Through this program, 
which currently is unfunded, the IHS would provide grants to 
tribally-controlled community colleges and vocational 
institutions for the development of substance abuse counseling 
educational curricula.
    Finally, the bill would reauthorize the Home and Community-
Based Care Demonstration Program, which is currently unfunded. 
Under this program, the IHS would make grants to Indian tribes 
or tribal organizations to establish demonstration programs of 
home and community-based services for functionally disabled 
Indians. Grant recipients would be required to have a contract 
under the Indian Self-Determination Act. The number of 
demonstration programs that could be funded would be capped at 
24. Based on the budget request of the INS for fiscal year 
1997, CBO estimates that the cost of reauthorizing this program 
would be $22 million through fiscal year 2000.
    S. 1869 would also make several technical amendments to the 
Indian Health Care Improvement Act. The bill would expand the 
definition of a health profession to include allopathic 
medicine and any other health profession. This change would 
allow practitioners of allopathic medicine and other health 
professionals access to the benefits accorded under the act. 
According to the Indian Health Service, this expansion would 
involve no additional cost to the federal government. For 
example, recipients of Health Professions Scholarships do not 
declare their specialty until they have completed their 
training and their scholarship has ended. Thus, the change in 
the definition of health professions would not increase the 
number of individuals participating in this program and would 
not increase the federal government's costs.
    The bill would also relieve recipients of Indian Health 
Professions Scholarships of their service or payment obligation 
under certain circumstances. A recipient's obligation would be 
canceled upon his death, and the Secretary could waive or 
suspend the obligation if she determined that fulfillment would 
cause the recipient undue hardship. The obligation could be 
discharged under Chapter 11 bankruptcy only if the discharge 
were granted five or more years after the first payment was due 
and if the bankruptcy court determined that it would be 
unconscionable not to discharge the obligation. Because the 
scholarship program is currently governed by the Public Health 
Service Act, which also permits these waivers, these provisions 
would not increase the costs of the federal government.
    Finally, S. 1869 would affect reimbursement of the federal 
government, tribes and tribal organizations by third-party 
payers. Tribes, tribal organizations and the federal government 
could be reimbursed for reasonable charges incurred in 
providing health services. Current law only allows the recovery 
of reasonable expenses incurred. According to the Indian Health 
Service, this provision would not result in any additional 
costs to the federal government. Under the proposal, the 
federal government, tribal organizations and tribes could also 
recover damages against the fiduciaries of employee benefit 
plans or insurance companies that are third-party providers and 
that fail to give reasonable assurances that they can 
sufficiently cover the benefits owed. CBO is unable to 
determine the precise amount of these offsetting collections at 
this time.
    7. Pay-as-you-go considerations: None.
    8. Estimated cost to State and local governments: This bill 
contains no intergovernmental mandates as defined in P.L. 104-4 
and would impose no costs on state, local or tribal 
governments.
    The bill would reauthorize appropriations for three 
programs that provide grant money to tribal governments and 
organizations for the provision of health care services and 
training. Assuming that the amounts authorized are 
appropriated, CBO estimates that tribal governments and 
organizations would receive about $6 million annually through 
fiscal year 2000. In addition, the bill would reauthorize 
appropriations for a demonstration program under which the 
California Rural Indian Health Board, a nonprofit organization, 
provides health care to Indians in California. If the amounts 
authorized are appropriated, CBO estimates that the Board would 
receive about $250,000 annually through fiscal year 2000.
    The bill would also extend the life of another 
demonstration program by four years. Under this program, 
tribally operated health facilities, which are chosen by the 
Secretary of Health and Human Services, are allowed to directly 
bill and receive payments for health services provided under 
the Medicare and Medicaid programs. The bill would also expand 
the program from four to twelve facilities. The facilities that 
are currently participating are reporting that the program has 
had a favorable impact on their budgets by increasing the 
efficiency and decreasing the turn-around time of the billing 
and payment process. When the demonstration program ends, bills 
and payments will be channeled through the IHS.
    Finally, the bill would clarify that tribal governments and 
organizations can collect from third party payers of health 
care services the reasonable charges billed, rather than the 
reasonable expenses incurred. Tribal governments and 
organizations have reported that some third-party payers have 
refused to pay for overhead and administrative costs billed to 
them. To the extent that this refusal to pay occurs, the 
clarification would expand offsetting collections by tribal 
governments and organizations.
    9. Estimated impact on the private sector: S. 1869 does not 
include any private sector mandates as defined in P.L. 104-4.
    10. Estimate comparison: None.
    11. Previous CBO estimate: None.
    12. Estimate prepared by: Federal Cost Estimate: Anne Hunt; 
State and Local Cost Estimate: John Patterson; and Private 
Sector Mandate Estimate: Julia Matson.
    13. Estimate approved by: Paul N. Van de Water, Assistant 
Director for Budget Analysis.

                      Regulatory Impact Statement

    Paragraph 11(b) of rule XXVI of the Standing Rules of the 
Senate requires each report accompanying a bill to evaluate the 
regulatory and paperwork impact that would be incurred in 
carrying out the bill. The Committee believes that passing S. 
1869 will create minimal regulatory or paperwork impacts.

                        Executive Communications

    The Committee received the following executive 
communication from the Honorable Donna E. Shalala, Secretary of 
the U.S. Department of Health and Human Services, regarding S. 
1869:

                The Secretary of Health and Human Services,
                                     Washington, DC, July 17, 1996.
Hon. John McCain,
Chairman, Committee on Indian Affairs,
U.S. Senate, Washington, DC.
    Dear Mr. Chairman: This is in response to your request for 
a report on S. 1869, the Indian Health Care Improvement 
Technical Corrections Act of 1996.
    In summary, we support S. 1869, as the bill would authorize 
the continuation through fiscal year 2000 of five tribal health 
care demonstration programs that are making progress, and that 
may provide models for other initiatives elsewhere among Indian 
communities. We also recommend a minor change to provisions in 
the bill concerning collections from third party payers.
    S. 1869 would extend through fiscal year 2000 the 
authorities for five Indian health care demonstration programs: 
the California health services demonstration program, the 
Medicare and Medicaid demonstration program, the Gallop alcohol 
and substance abuse treatment center demonstration program, the 
substance abuse counselor education demonstration program, and 
the home and community-based care demonstration program. S. 
1869 would also enact a number of minor and technical 
provisions, including a provision that, in relation to third 
party payer collections, would change the term ``expenses'' to 
``charges''.
    The five demonstration programs are making progress in 
enhancing and expanding services for Indians and may serve as 
models for other tribes. We support continuing these 
demonstrations.
    We recommend, however, that the term ``expenses'' (in 
relation to collections from third party payers) be retained. 
Because Indian health programs do not bill their patients, the 
use of the term ``charges'' would not seem to be helpful in the 
context of Indian health services.
    We therefore recommend that bill be favorably considered, 
with the minor change suggested above for third party 
collections.
    We are advised by the Office of Management and Budget that 
there is no objection to the presentation of this report from 
the standpoint of the Administration's program.
            Sincerely,
                                                  Donna E. Shalala.

                        Changes in Existing Law

    In compliance with subsection 12 of rule XXVI of the 
Standing Rules of the Senate, the Committee states that the 
enactment of S. 1869 will result in the following changes in 25 
U.S.C. 1603(n), 25 U.S.C. 1613a(b)(3), 25 U.S.C. 1613a(b)(4), 
25 U.S.C. 1613a(b)(5), 25 U.S.C. 1621e, 25 U.S.C. 1621j(g), 42 
U.S.C. 1395qq note, 25 U.S.C. 1665e(d), 25 U.S.C. 1665j(h), and 
25 U.S.C. 1680k(i), with existing language which is to be 
deleted in black brackets and the new language to be added in 
italic:

                           25 U.S.C. 1603(n)

    (n) ``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, [and allied health professions] an allied health 
profession, or any other health profession.
          * * * * * * *

                         25 U.S.C. 1613a(b)(3)

    (3)(A) [The active duty service obligation prescribed under 
section 338C of the Public Health Service Act (42 U.S.C. 254m) 
shall be met by a recipient of an Indian Health Scholarship by 
service] The active duty service obligation under a written 
contract with the Secretary under section 338A of the Public 
Health Service Act (42 U.S.C. 2541) that an individual has 
entered into under that section shall, if that individual is a 
recipient of an Indian Health Scholarship, be met in full-time 
practice, by service--
          (iii) in a program assisted under title V of this 
        Act; [or]
          (iv) 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[.]; or
          (v) in an academic setting (including a program that 
        receives funding under section 102, 112, or 114, or any 
        other academic setting that the Secretary, acting 
        through the Service, determines to be appropriate for 
        the purposes of this clause) in which the major duties 
        and responsibilities of the recipient are the 
        recruitment and training of Indian health professionals 
        in the discipline of that recipient in a manner 
        consistent with the purpose of this title, as specified 
        in section 101.
    (B) At the request of any individual who has entered into a 
contract referred to in subparagraph (A) and who receives a 
degree in medicine (including osteopathic or allopathic 
medicine), dentistry, optometry, podiatry, or pharmacy, 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:
          (i) No period of internship, residency, or other 
        advanced clinical training shall be counted as 
        satisfying any period of obligated service that is 
        required under this section.
          (ii) 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).
          (iii) The active duty service obligation will be 
        served in the health profession of that individual, in 
        a manner consistent with clauses (i) through (v) of 
        subparagraph (A).
    [B] (C) A recipient of an Indian Health Scholarship may, at 
the election of the recipient, meet the active duty service 
obligation [prescribed under Section 338C of the Public Health 
Service Act (42 U.S.C. 254m) by service in a program specified 
in subparagraph (A)] described in subparagraph (A) by service 
in a program specified in that subparagraph that--
          (i) is located on the reservation of the tribe in 
        which the recipient is enrolled; or
          (ii) serves the tribe in which the recipient is 
        enrolled.
    [C] (D) [Subject to subparagraph (B),] Subject to 
subparagraph (C), the Secretary, in making assignments of 
Indian Health Scholarship recipients required to meet the 
active duty service obligation [prescribed under section 338C 
of the Public Health Service Act (42 U.S.C. 254m] described in 
subparagraph (A), shall give priority to assigning individuals 
to service in those programs specified in subparagraph (A) 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.
          * * * * * * *

                         25 U.S.C. 1613a(b)(4)

    [(B) the period of obligated service specified in section 
338A(f)(1)(B)(iv) of the Public Health Service Act (42 U.S.C. 
254m(f)(1)(B)(iv)) shall be equal to the greater of--] (B) the 
period of obligated service described in paragraph (3)(A) shall 
be equal to the greater of--
    (C) the amount of the monthly stipend specified in section 
338A(g)(1)(B) of the Public Health Service Act [(42 U.S.C. 
254m(g)(1)(1)(B))] (42 U.S.C. 2541(g)(1)(B))
          * * * * * * *

                         25 U.S.C. 1613a(b)(5)

    (C) Upon the death of an individual who receives an Indian 
Health Scholarship, any obligation of that individual for 
service or payment that relates to that scholarship shall be 
canceled.
    (D) 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--
          (i) it is not possible for the recipient to meet that 
        obligation or make that payment;
          (ii) requiring that recipient to meet that obligation 
        or make that payment would result in extreme hardship 
        to the recipient; or
          (iii) the enforcement of the requirement to meet the 
        obligation or make the payment would be unconscionable.
    (E) 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.
    (F) 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.
          * * * * * * *

                            25 U.S.C. 1621e

    [(a) Except as provided] (a) Right of Recovery.--Except as 
provided in subsection (f), the United States, an Indian tribe, 
or a tribal organization shall have the right to recover [the 
reasonable expenses incurred] the reasonable charges billed by 
the Secretary, an Indian tribe, or a tribal organization [in 
providing] for providing health services, through the Service, 
an Indian tribe, or a tribal organization, to any individual to 
the same extent that such individual or any nongovernmental 
provider of such services, would be eligible to receive 
reimbursement or indemnification [for such expenses] for such 
charges if--
          (2) such individual had been required to pay [such 
        expenses] such charges and did pay [such expenses] such 
        charges.
    [(b) Subsection (a)] (b) Recovery Against State With 
Workers' Compensation Laws or No-Fault Automobile Accident 
Insurance Program.--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--
    [(c) No law] (c) Prohibition of State Law or Contract 
Provision Impediment to Right of Recovery._No law of any State, 
or of any political subdivision of a State, and no provision of 
any contract entered into or renewed after the date of 
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 a tribal organization under section (a).
    [(d) No action] (d) Right to Damages.--No action taken by 
the United States, an Indian Tribe, or a tribal organization to 
enforce the right of recovery provided under subsection (a) 
shall affect the right of any person to any damages (other than 
damages for the cost of health services provided by the 
Secretary through the Service).
    [(e) The United States] (e) Intervention or Separate Civil 
Action.--The United States, an Indian tribe, or a tribal 
organization may enforce the right of recovery provided under 
subsection (a) by--
          [(2) instituting a separate civil action, after 
        providing to such individual, or to the representative 
        or heirs of such individual, notice of the intention of 
        the United States, an Indian tribe, or a tribal 
        organization to institute a separate civil action.] (2) 
        while making all reasonable efforts to provide notice 
        of the action to the individual to whom health services 
        are provided prior to the filing of the action, 
        instituting a civil action.
    [(f) The United States] (f) Services Covered Under a Self-
Insurance Plan.--The United States shall not have a right of 
recovery under this section if the illness, injury, or 
disability for which health services were provided is covered 
under a self-insurance plan funded by an Indian tribe or tribal 
organization.
    (g) Costs of Action.--In any action brought to enforce this 
section, the court shall award any prevailing plaintiff costs, 
including attorneys' fees that were reasonably incurred in that 
action.
    (h) Right of Recovery for Failure To Provide Reasonable 
Assurances.--The United States, an Indian tribe, or a tribal 
organization shall have the right to recover damages against 
any fiduciary of an insurance company or employee benefit plan 
that is a provider referred to in subsection (a) who--
          (1) fails to provide reasonable assurances that such 
        insurance company or employee benefit plan has funds 
        that are sufficient to pay all benefits owed by that 
        insurance company or employee benefit plan in its 
        capacity as such a provider; or
          (2) otherwise hinders or prevents recovery under 
        subsection (a), including hindering the pursuit of any 
        claim for a remedy that may be asserted by a 
        beneficiary or participant covered under subsection (a) 
        under any other applicable Federal or State law.
          * * * * * * *

                           25 U.S.C. 1621j(g)

    (g) There are authorized to be appropriated for each of the 
fiscal years [1993, 1994, 1995, 1996, and 1997] 1996 through 
2000 such sums as may be necessary to carry out the purposes of 
this section.
          * * * * * * *

                           25 U.S.C. 1645(c)

    (1)(D) the facility is accredited by the Joint Commission 
on Accreditation of Hospitals, or has submitted a plan, which 
has been approved by the Secretary, for achieving such 
accreditation [prior to October 1, 1990] on or before the date 
which is 1 year after the date of submission of the plan.
    (2) From among the qualified applicants, the Secretary 
shall[, prior to October 1, 1989, select no more than 4] select 
no more than 12 facilities to participate in the demonstration 
program described in subsection (a). The demonstration program 
described in subsection (a) shall begin by no later than 
October 1, 1991, and end on [September 30, 1996] September 30, 
2000.
          * * * * * * *

                           25 U.S.C. 1665e(d)

    [(d) Authorization of Appropriations.--There are authorized 
to be appropriated--
          (1) to carry out the purposes of subsection (b)(1) of 
        this section--
                  (A) $400,000 for fiscal year 1993;
                  (B) $400,000 for fiscal year 1994; and
                  (C) $500,000 for fiscal year 1995;
          (2) to carry out the purposes of subsection (b)(2) of 
        this section--
                  (A) $100,000 for fiscal year 1993;
                  (B) $125,000 for fiscal year 1994; and
                  (C) $150,000 for fiscal year 1995;
          (3) to carry out the purposes of subsection (b)(3) of 
        this section--
                  (A) $75,000 for fiscal year 1993;
                  (B) $85,000 for fiscal year 1994; and
                  (C) $100,000 for fiscal year 1995;
          (4) to carry out the purposes of subsection (b)(4) of 
        this section, $150,000 for each of fiscal years 1993, 
        1994, and 1995; and
          (5) to carry out the purposes of subsection (b)(5) of 
        this section--
                  (A) $75,000 for fiscal year 1993;
                  (B) $90,000 for fiscal year 1994; and
                  (C) $100,000 for fiscal year 1995.]
    (d) Authorization of Appropriations._There are authorized 
to be appropriated, for each of fiscal years 1996 through 2000, 
such sums as may be necessary to carry out subsection (b).
          * * * * * * *

                           25 U.S.C. 1665j(h)

    [There are authorized to be appropriated for each for the 
fiscal years 1993, 1994, 1995, 1996, and 1997] 1996 through 
2000, such sums as may be necessary to carry out the purposes 
of this section. Such sums shall remain available until 
expended.
          * * * * * * *

                           25 U.S.C. 1680k(i)

    (i) [There are authorized to be appropriated for each of 
the fiscal years 1993, 1994, 1995, 1996, and 1997] 1996 through 
2000, such sums as may be necessary to carry out the purposes 
of this section. Such sums shall remain available until 
expended.