Senate Report 107-97 - STROKE TREATMENT AND ONGOING PREVENTION ACT OF 2001

[Senate Report 107-97]
[From the U.S. Government Publishing Office]

Calendar No. 222
107th Congress Report
SENATE
1st Session 107-97

======================================================================

STROKE TREATMENT AND ONGOING PREVENTION ACT OF 2001

_______

November 9, 2001.--Ordered to be printed

_______

Mr. Kennedy, from the Committee on Health, Education, Labor, and
Pensions, submitted the following

R E P O R T

together with

ADDITIONAL VIEWS

[To accompany S. 1274]

The Committee on Health, Education, Labor, and Pensions, to
which was referred the bill (S. 1274) to amend the Public
Health Service Act to provide programs for the prevention,
treatment, and rehabilitation of stroke, having considered the
same, reports favorably thereon and recommends that the bill do
pass.

CONTENTS

Page
I. Purpose and summary..............................................1
II. Background and need for the legislation..........................2
III. History of the legislation.......................................5
IV. Explanation of bill and committee views..........................5
V. Cost estimate....................................................7
VI. Regulatory impact statement.....................................10
VII. Application of law to the legislative branch....................10
VIII.Section-by-section analysis.....................................10

IX. Additional views................................................13
X. Changes in existing law.........................................14

I. Purpose and Summary

The Stroke Treatment and Ongoing Prevention Act of 2001
authorizes initiatives at the State and Federal levels to
improve and enhance the Nation's capacity to provide effective
treatment for stroke.

II. Background and Need for Legislation

Stroke is a loss of brain function resulting from an
interruption of the blood supply to the brain, due either to
ischemia or hemorrhage. Stroke often causes disability and
frequently results in death, due to the tissue damage to the
brain that results from an interrupted blood supply. The
effects of a vascular accident in the brain are particularly
severe, since neural tissue has an extremely limited capacity
to regenerate. Even a brief interruption to the blood flow can
cause severe neurological deficits.
There are two different types of stroke or Brain Attack--
ischemic stroke and hemorrhagic stroke. An ischemic stroke is
caused when a blood clot blocks or ``plugs'' a blood vessel in
the brain. There are two ways that a blood-clot stroke can
occur. An embolic stroke occurs when a blood clot travels from
other parts of the body (for example, the heart) to the neck or
brain and blocks a blood vessel. In a thrombotic stroke, a
blood clot (thrombus) forms inside one of the brain's arteries
and blocks blood flow. This usually happens inside an artery
that has already been narrowed by atherosclerosis, a condition
where fatty deposits (plaques) build up along the walls of
blood vessels. Ischemic stroke is the most common type of
stroke (80 percent-85 percent of strokes are ischemic).
A hemorrhagic stroke is caused when a blood vessel in the
brain breaks or ruptures. There are two types of hemorrhagic
stroke: a subarachnoid hemorrhage and a intracerebral
hemorrhage. With a subarachnoid hemorrhage, bleeding occurs in
the space around the brain. Often this is due to an aneurysm--a
weak or thin spot on a blood vessel wall. An intracerebral
hemorrhage involves bleeding within the brain tissue itself,
and this is the more common form. Hemorrhagic stroke occurs in
10 percent of stroke sufferers. While there are mild to severe
strokes, the outcomes of a hemorrhagic stroke are usually
severe.
The consequences of a stroke very depending on the region
of the brain that is deprived of blood supply. Symptoms of
stroke can include blurred or lost vision, difficulties in
forming or comprehending speech, muscle weakness or paralysis,
disorientation, loss of sensation in a part of the body, loss
of consciousness or death. If the blood flow is interrupted for
longer than a few seconds, neurons in the ischemic area die,
causing permanent losses in brain function.
Stroke has a profound impact on the health of the people of
the United States. It is the third leading cause of death in
the United States. There are roughly 700,000-750,000 strokes in
the United States each year, and almost 160,000 Americans die
each year from stroke. Every minute in the United States, an
individual experiences a stroke. Every 3.3 minutes an
individual dies from one.
Over the course of a lifetime, four out of every five
families in the United States will be touched by stroke.
Currently, there are four million Americans living with the
effects of stroke. 15 percent to 30 percent of stroke survivors
are permanently disabled. 55 percent of stroke survivors have
some level of disability. 40 percent of these patients feel
they can no longer visit people; almost 70 percent report that
they cannot read; 50 percent need day-hospital services; 40
percent need home help; 40 percent have a visiting nurse; and
14 percent need Meals on Wheels.
The economic impact of stroke is similarly profound. Stroke
costs the United States $30 billion each year. The average cost
per patient for the first 90 days following a stroke is
$15,000. The lifetime costs of stroke exceed $90,000 per
patient for ischemic stroke and over $225,000 per patient for
subarachnoid hemorrhage.
Improving the quality of treatment provided to stroke
patients and enhancing stroke prevention would save lives and
reduce the economic toll taken by this disorder. However, there
is strong evidence that stroke care and prevention is not
adequate.
Recent developments in the treatment of persons with stroke
could save lives and reduce disability if properly and promptly
administered. Thrombolytic medications can improve stroke
outcomes if administered rapidly after the onset of a stroke,
yet few patients receive these therapies. Nationally, only 2
percent to 3 percent of patients with stroke are being treated
with the appropriate thrombolytic agent. Interventional stroke
therapies, such as stenting or endovascular treatment of
aneurysms, may also be effective for some patients.
Research into new treatments for stroke is ongoing, and
promising advances are being made continuously. Advances in
imaging, interventional radiology, pharmacology and many other
disciplines provide new hope that more effective stroke
treatments will be found.
While research promises new treatments for the future,
existing treatments are not being administered in the most
effective manner even now. For example, in a study of North
Carolina's stroke treatment facilities, 66 percent of hospitals
did not have stroke protocols and 82 percent did not have rapid
identification for patients experiencing acute stroke. A 1995
study found that almost half of all stroke patients who went
through the Reading, Ohio Emergency Medical Services System
were dispatched as having something other than stroke and a
quarter of all patients identified as having stroke by
paramedics were later discovered to have another cause for
their illness. A 1993 study of patients who had a stroke while
they were inpatient found a median delay between stroke
recognition and neurological evaluation of 2.5 hours. Improving
the delivery of existing therapy can thus have a marked effect
on the morbidity and mortality caused by stroke.
Prompt recognition of the symptoms of a stroke is a key to
effective treatment, yet public awareness of the symptoms of
stroke is poor. Since few Americans recognize the symptoms of
stroke, crucial hours are often lost before patients receive
medical care. For example, in a 1989 survey of 500 San
Francisco residents, 65 percent of those surveyed were unable
to correctly identify any of the early stroke warning signs
when given a list of symptoms. In a national survey, 29 percent
of respondents could not name the brain as the site of a stroke
and only 44 percent identified weakness or loss of feeling in
an arm or leg as a symptom of stroke. The International Stroke
Trial found that only 4 percent of the 19,000 patients studied
presented within 3 hours of symptom onset and only 16 percent
presented within 6 hours. The average time between the onset of
symptoms and medical treatment is a shocking 13 hours.
Recent research provided the committee with important
insight into ways to improve outcomes for patients experiencing
stroke. This research (detailed below) showed that an
integrated and comprehensive system of stroke care can save
lives and reduce disability associated with stroke. Two strands
of research were particularly important in demonstrating the
likely benefits of integrated stroke care systems. The first
shows that patients treated for stroke at stroke centers
experience significantly better outcomes than those treated in
other hospital settings. The second shows that implementing
statewide systems of care for trauma significantly reduced
death rates among trauma victims.
Several comprehensive studies indicate that patients
experience improved clinical outcomes if treated at designated
stroke centers. A series of 19 clinical trials that included
3,249 patients in European hospitals demonstrated significantly
reduced rates of death, disability and institutionalization for
patients treated in stroke centers compared to those treated in
other hospital settings (meta-analyses reported in Stroke
(1997) 28:2139; British Medical Journal (1997) 314: 1151).
Based on this data, the number needed to treat in order to
prevent one death was 22. Extrapolating from this data,
treating all stroke victims in the appropriate hospital setting
might be expected to save approximately 30,000 lives in the
United States.
To be most effective, stroke centers should form part of an
integrated system of stroke care to ensure that a patient
receives the optimal therapy at the time when it is most
effective. Stroke care systems should include initiatives to
prevent stroke through reduction in risk factors, pre-hospital
and emergency care, hospital care, rehabilitation,
reintegration into the community, surveillance and research.
The experience of several states that have implemented
comprehensive trauma care systems, consisting of most or all of
the elements identified above, is instructive in showing the
potential benefits of similar systems of care for stroke. These
trauma care systems have been shown to significantly improve
outcomes for patients. For example, the trauma care system
implemented in Nebraska reduced pre-hospital death rates by 28
percent and hospital deaths by 17 percent (data reported in
Journal of Trauma (1985) 25: 575).
The odds of survival from trauma in Oregon increased by 20
percent in the years following implementation of the state's
trauma care system (data reported in Journal of Trauma: Injury,
Infection and Critical Care (1996) 40: 536). Comparing patient
outcomes in states that have implemented trauma care systems to
similar states that have not is a particularly important
measure of these systems' effectiveness. Comparing patient
outcomes in Oregon to those in neighboring Washington (where a
trauma system had not been implemented) revealed that patients
had a significantly better chance of surviving trauma if
treated in Oregon rather than Washington (data reported in
Journal of Trauma: Injury, Infection, and Critical Care (1997)
43:122; ; Journal of Trauma: Injury, Infection, and Critical
Care (1998) 44:609). The beneficial effects of a statewide
trauma care system were confirmed by a similar study showing
that trauma survival rates for pediatric patients were also
significantly better in Oregon than in Washington (data
reported in the Journal of Trauma: Injury, Infection, and
Critical Care (1997) 42:514).
While trauma care and stroke care present somewhat
different health care challenges, it is the committee's belief
that instituting statewide systems of stroke care can provide
benefits to patients analogous to those demonstrated to occur
after implementation of statewide trauma care systems.
To save lives, reduce disability and improve the quality of
stroke care, the Stroke Treatment and Ongoing Prevention (STOP
Stroke) Act authorizes important public health initiatives to
help patients with symptoms of stroke receive timely and
effective care.

III. History of the Legislation

The Stroke Treatment and Ongoing Prevention (STOP Stroke)
Act of 2001 was introduced on July 31, 2001, by Senator
Kennedy, for himself and Senator Frist, Senator Dodd, Senator
Hutchinson, Senator Jeffords, Senator Collins, Senator
Bingaman, Senator Edwards, Senator Murray, and Senator
Sessions. The bill was referred to the Senate Committee on
Health, Education, Labor, and Pensions. On August 1, 2001, the
Senate Committee on Health, Education, Labor, and Pensions held
an executive session to consider S. 1274. S. 1274 was ordered
reported favorably by a unanimous voice vote.

IV. Explanation of the Bill and Committee Views

The committee seeks to improve systems for the treatment of
stroke throughout the United States by reporting favorably the
Stroke Treatment and Ongoing Prevention (STOP Stroke) Act of
2001. The Act establishes a grant program for States to
implement systems ofstroke care that will give health
professionals the equipment and training they need to treat this
disorder. The initial point of contact between a stroke patient and
medical care is usually an emergency medical technician. Grants
authorized by the Act may be used to train emergency medical personnel
to provide more effective care to stroke patients in the crucial first
few hours after an attack.
The Act provides important new resources for States to
improve the standard of care given to stroke patients in
hospitals. The legislation will assist States in increasing the
quality of stroke care available in rural hospitals through
improvements in telemedicine and other communications
technology.
The Act directs the Secretary of Health and Human Services
to conduct a national media campaign to inform the public about
the symptoms of stroke, so that patients receive prompt medical
care. The legislation also creates the Paul Coverdell Stroke
Registry and Clearinghouse, which will collect data about the
care of stroke patients and assist in the development of more
effective treatments
Finally, the STOP Stroke Act establishes continuing
education programs for medical professionals in the use of new
techniques for the prevention and treatment of stroke.
Increased public information on the symptoms of stroke will
help stroke patients and their families know to seek medical
care promptly. Better training of emergency medical personnel
will help ensure that stroke patients receive lifesaving
medications when they are most effective. Improved systems of
stroke care will help patients receive the quality treatment
needed to save lives and reduce disability.
The committee particularly wishes to stress that it views
stroke as a national problem and intends for the initiatives in
the Act to be national in scope. While particular areas of the
nation may have differing needs with regard to stroke treatment
or prevention, the committee intends for the Act to provide for
improvements in stroke prevention, treatment and care
throughout the nation.
In addition, the committee wishes to clarify its views
regarding the following sections of the Act.

Section 2801. Stroke prevention and education campaign

Section 2801 instructs the Secretary of Health and Human
Services to carry out a national education and information
campaign to promote stroke prevention and increase the number
of stroke patients who seek immediate treatment. The committee
believes that broad consultation will be important as the
Secretary carries out the duties described in this section.
Thus, the list of entities with whom the Secretary may consult
that is provided in subsection 9(a) of this Section is intended
to be illustrative, rather than restrictive.
The committee believes that evaluation of the success of
the program authorized in this section is highly important.
Thus, the committee expects that the Department of Health and
Human Services will design and implement a rigorous program (as
described in subsection (b)(7)) to evaluate the effectiveness
of the program authorized under this section.

Section 2812. Paul Coverdell National Acute Stroke Registry and
Clearinghouse

In approving subsection (b) of this section, the committee
recognizes that a wealth of research has already been conducted
regarding the activities described in paragraphs (1) through
(5). It is not the committee's intention that the Secretary
should duplicate existing data in these areas, but rather that
the Secretary should conduct new research where necessary to
supplement gaps in existing data. Where data exist, it is the
committee's intention that the Secretary disseminate that data
widely within the health care community so that stroke care can
be made more effective. In doing so, it is the committee's
intention that the Secretary ensure effective coordination
among the agencies within the Department of Health and Human
Services.

Section 2821. Establishment of program for improving stroke care

This section authorizes the Secretary to award grants for
the establishment of statewide stroke prevention, treatment and
rehabilitation systems. Such systems should include prevention,
pre-hospital and emergency care, hospital care, rehabilitation,
reintegration into the community, surveillance and research.
An important component of stroke care systems is a stroke
care center or network of centers, where patients experiencing
stroke can receive treatment of the highest caliber from health
professionals with special training and experience in stroke
care. Such centers use multidisciplinary teams of health care
professionals to provide the most advanced approaches and
techniques in prevention, treatment and rehabilitation of
stroke. Such centers may also provide improved services for
recognizing the symptoms of transient ischemic episodes, so
that patients may receive care designed to prevent the onset of
a major stroke. A further component of a stroke care center may
be to provide high quality rehabilitative care, consistent with
the standards established by the Secretary under section 2823.
While the balance between providing care at stroke centers
or at other hospital facilities must be struck by each State
according to its own needs, the committee takes note of
scientific findings showing that patients receiving stroke care
at stroke care centers experience better outcomes than patients
treated at facilities with less specialized expertise,
facilities or training. The committee recognizes, however, that
many patients experiencing stroke may not be treated at a
stroke center. These health care facilities should be supported
to ensure that they can provide an appropriate standard of care
before possible transport to a center. Linkages between stroke
care centers and other health care facilities will be crucial
in ensuring that patients in rural or otherwise medically
underserved communities have access to quality stroke care.
Telemedicine and other communication technologies that allow
for consultation between widely dispersed sites will likely
play an essential role in these linkages. Telemedicine is a
broad term describing the delivery of health care or sharing of
medical knowledge over a distance using telecommunication
systems. As such, it includes, but is not limited to,
techniques such as telephone consultation, interactive
televideo and digital clinical image transmission.

Sec. 2831. Medical professional development in advanced stroke
treatment and prevention

Section 2831 authorizes the Secretary to make grants for
the development and implementation of educational programs on
the prevention and treatment of stroke. The language of the
Section lists several health care specialties that may benefit
from such educational programs. It is the committee's view that
this list is illustrative rather than restrictive of the types
of health care professionals who may participate in the
activities authorized under this section. The exclusion of a
particular health care specialty from the illustrative list
provided in this section should not in any way be taken to
imply that the specialty in question should be excluded from
the activities authorized in the section.

V. Cost Estimate

congressional budget office cost estimate

S. 1274--Stroke Treatment and Ongoing Prevention Act of 2001

Summary: S. 1274 would amend the Public Health Service Act
to authorize the Secretary of Health and Human Services (HHS)
to engage in a number of new activities to inform the public
about the symptons of stroke, and to improve systems of stroke
care in order to give health professionals the equipment and
training they need to treat this disorder.
S. 1274 would authorize specific sums for fiscal years 2002
through 2006 for grant programs to states to implement systems
of stroke care. In addition, the bill would authorize $40
million in fiscal year 2002 and such sums as may be necessary
in 2003 through 2006 for a national stroke education and
prevention campaign. Finally, S. 1274 would authorize such sums
as may be necessary for the establishment of a national acute
stroke registry and clearinghouse and for medical professional
development in advanced stroke treatment and prevention in
fiscal years 2002 through 2006.
Assuming the appropriation of the necessary amounts, and
including adjustments for anticipated inflation, CBO estimates
that implementing S. 1274 would cost $47 million in 2002 and
$594 million over the 2002-2006 period. Without inflation
adjustments, the five-year total would be $584 million.
Enacting S. 1274 would not affect direct spending or receipts;
therefore, pay-as-you-go procedures would not apply.
S. 1274 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
However the bill would provide funding to public and nonprofit
private entities for programs related to stroke care.
Estimated Cost to the Federal Government: The estimated
budgetary impact of S. 1274 is shown in Table 1. For this
estimate, CBO assumes that the bill will be enacted this fall
and that the authorized and estimated amounts will be
appropriated each year. Table 1 summarizes the budgetary impact
of the legislation under two different sets of assumptions. The
first set of assumptions provides the estimated levels of
authorizations with annual adjustments for anticipated
inflation. The second set does not include any such inflation
adjustments. The costs of this legislation fall within budget
function 550 (health).

TABLE 1.--SUMMARY OF ESTIMATED COSTS OF S. 1274
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--

--------------------------------------------
2002 2003 2004 2005 2006
----------------------------------------------------------------------------------------------------------------
CHANGES IN SPENDING SUBJECT TO APPROPRIATION

With Adjustments for Inflation

Estimated authorization level...................................... 112 138 140 166 192
Estimated outlays.................................................. 47 104 124 147 171
Without Adjustments for Inflation

Estimated authorization level...................................... 112 137 137 162 187
Estimated outlays.................................................. 47 103 123 144 167
----------------------------------------------------------------------------------------------------------------

Basis of estimate: S. 1274 would direct the Secretary of
HHS to engage in a number of activities related to the
treatment and prevention of stroke. Table 2 details estimated
authorization levels (adjusted for inflation) for the four
programs authorized under the bill.
The bill would direct the Secretary to conduct a national
media campaign to promote stroke prevention and increase the
number of stroke patients who seek immediate treatment. The
bill would authorize $40 million in fiscal year 2002 and such
sums as may be necessary in fiscal years 2003 through 2006 for
such purposes. If the necessary sums are appropriated, CBO
estimates that this provision would cost $172 million over the
2002-2006 period.

TABLE 2.--ESTIMATED AUTHORIZATION LEVELS FOR S. 1274 (ASSUMING ANNUAL ADJUSTMENTS FOR INFLATION)
----------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--

Stroke Prevention and Education Campaign........................... 40 41 42 43 43
Paul Coverdell National Acute Stroke Registry and Clearinghouse.... 12 12 13 13 13
Grants to States................................................... 50 75 75 100 125
Medical professional development in advanced stroke treatment and 10 10 10 11 11
prevention........................................................
--------------------------------------------
Total........................................................ 112 138 140 166 192
----------------------------------------------------------------------------------------------------------------

The bill also would direct the Secretary to establish and
maintain the Paul Coverdell National Acute Stroke Registry and
Clearinghouse, which would collect data on the care of stroke
patients and assist in the development of more effective
treatments. The bill would authorize such sums as may be
necessary for fiscal years 2002 through 2006 for this
provision. If the necessary sums are appropriated, CBO
estimates that establishment of the registry and clearinghouse
would cost $52 million over the 2002-2006 period.
The bill also would establish a grant program for states to
implement systems of stroke care and train health care
professionals in the prevention and treatment of stroke. The
bill specifies the sums to be appropriated in each of fiscal
years 2002 though 2006, for a five-year total of $425 million.
CBO estimates that outlays from those grants would total $328
million over the 2002-2006 period.
The bill also would direct the Secretary to make grants to
public and nonprofit private entities for the development and
implementation of continuing education programs for medical
professionals in the use of newly developed approaches for the
prevention and treatment of stroke. The bill would authorize
such sums as may be necessary for fiscal years 2002 through
2006 for this provision. If the necessary sums are
appropriated, CBO estimates that such programs would cost $43
million over the 2002-2006 period.
CBO estimates the necessary amounts for these programs
would total $112 million in 2002 and $748 million over the
2002-2006 period. Based on spending patterns for
similarprograms, CBO estimates that outlays for these programs would
total $47 million in 2002 and $594 million over the 2002-2006 period.
Pay-as-you-go considerations: None.
Estimated impact on State, local, and tribal governments:
S. 1274 contains no intergovernmental mandates as defined in
UMRA. The bill would authorize $425 million in State grants for
stroke prevention, treatment, and rehabilitation systems over
the 2002-2006 period. To be eligible for the grants, States
would have to develop a statewide stroke care system that
provides stroke treatment in accordance with federally
established standards. After the first year of the grants,
States would have to provide matching support for the program,
either as in-kind contributions or as cash funding: one-quarter
of the program's funding in years two and three; one-third in
year four; and one-half in subsequent years. States also would
be eligible for planning grants that would not have matching
requirements.
Estimated impact on the private sector: S. 1274 contains no
private-sector mandates as defined in UMRA.
Estimate prepared by: Federal costs: Niall Brennan; impact
on State, local, and tribal governments: Leo Lex; impact on the
private sector: Kate Bloniarz.
Estimate approved by: Peter H. Fontaine, Deputy Assistant
Director for Budget Analysis.

VI. Regulatory Impact Statement

The committee has determined that there will be no
increases in the regulatory burden of paperwork as a result of
this bill.

VII. Application of Law to the Legislative Branch

Section 102(b)(3) of Public Law 104-1, the Congressional
Accountability Act (CAA), requires a description of the
application of the bill to the legislative branch. S. 2731
amends the Public Health Service Act to enhance the treatment
and prevention of stroke throughout the nation. This bill does
not apply to the legislative branch.

VIII. Section-by-Section Analysis

Section 1. Short title

This Act may be cited as the ``Stroke Treatment and Ongoing
Prevention Act of 2001''.

Section 2. Findings and goal

This section describes the findings of Congress that stroke
has a significant impact on the health of thousands of
Americans, and that stroke treatment is in need of improvement
throughout the United States. The section also states that the
goal of the Act is to improve the provision of stroke care in
every State and territory and in the District of Columbia, and
to increase public awareness about the prevention, detection,
and treatment of stroke.

Section 3. Systems for stroke prevention, treatment, and rehabilitation

The Act adds a new Title XXVIII to the Public Health
Service Act. Within the new Title, the Act creates the
following Sections.
Section 2801 authorizes the Secretary to carry out a
national education and information campaign to promote stroke
prevention and increase the number of stroke patients who seek
immediate treatment.
Section 2811 requires the Secretary, with respect to stroke
care, to (1) support and evaluate a grant program to enable a
State to develop statewide stroke care systems; (2) foster the
development of appropriate, modern systems of stroke care; and
(3) provide to State and local agencies technical assistance.
Sec 2812 requires the Secretary to maintain the Paul
Coverdell National Acute Stroke Registry and Clearinghouse. The
section further requires the Secretary to ensure the
availability of published research on stroke or, where
necessary, conduct research concerning stroke in areas
specified in the Section
Section 2821 requires the Secretary to award grants to
States for the purpose of establishing statewide stroke
prevention, treatment, and rehabilitation systems. The
committee's views on this section are provided in more detail
above. In general, the section requires that stroke care
systems proposed or implemented with funds granted under this
section be consistent with standards adopted by the recipient
State and further requires that those State standards take into
account national standards. In fiscal year 2004 and beyond, the
State standards must take into account national standards for
stroke care developed by the Secretary under section 2823.
The section further authorizes the Secretary to award
grants to assist States in formulating a plan to develop a
statewide stroke care system or for other specified purposes.
The section stipulates that a State may receive no more than
one such planning grant. The section calls upon the Secretary
to develop a model curriculum for training emergency medical
services personnel, in the identification, assessment,
stabilization, and prehospital treatment of stroke patients.
This model curriculum may, at the discretion of the State, be
adopted by a State for training emergency medical services
personnel.
Section 2822 requires provides that the Secretary may not
award a grant to a State unless the State agrees to make
available for each year during which the State receives funding
under such section, non-Federal contributions (in cash or in
kind) toward such costs in an amount equal to (A) for the
second and third fiscal years of such payments to the State,
not less than $1 for each $3 of Federal funds provided; (B) for
the fourth fiscal year of such payments to the State, not less
than $1 for each $2 of Federal funds; and (C) for any
subsequent fiscal year of such payments to the State, not less
than $1 for each $1 of Federal funds provided in such payments
for such fiscal year.
Section 2823 provides for an application process for States
wishing to receive grants authorized by section 2821. The
section further specifies that, to be eligible to receive
grants under section 2821, a State must adopt standards of care
for stroke patients in the acute, post-acute, and
rehabilitation phases of stroke. These standards must take into
account national standards, as determined by the Secretary.
The section further requires the Secretary to develop
standards of care for stroke patients in all phases of stroke
that may be adopted for guidance by the State and a model plan
for the establishment of statewide stroke care systems. In
fiscal year 2004 and beyond, the State standards must take into
account these national standards for stroke care developed by
the Secretary.
Section 2825 prohibits the Secretary from using grants
authorized under Section 2821 of the Act to (1) to make cash
payments to intended recipients of services provided pursuant
to such section; (2) to satisfy any requirement for the
expenditure of non-Federal funds as a condition for the receipt
of Federal funds; or (3) to provide financial assistance to any
entity other than a public or nonprofit private entity. The
prohibition may be waived if the Secretary finds that the
purpose described in section 2821(b) cannot otherwise be
carried out.
Section 2826 allows the Secretary to seek repayment of
funds granted under section 2821 if the recipient State expends
those funds in a manner inconsistent with the agreements made
by that State as a condition of receipt of funds.
Section 2827 directs the Secretary, in awarding grants
under section 2821, to give special consideration to any State
(1) in geographic areas in which there is a substantial rate of
disability resulting from stroke or a substantial incidence of
stroke; or (2) that demonstrates a significant need for
assistance in establishing a comprehensive stroke care system.
States with a significant need for assistance may be different
than those in which there is a substantial rate of disability
resulting from stroke or a substantial incidence of stroke, so
that grants under section 2821 may be awarded in geographic
areas other than those experiencing the highest rate of stroke.
Section 2828 requires the Secretary to provide to the State
(or to any public or nonprofit entity designated by the State)
any reasonable technical assistance with respect to the
planning, development, and operation of any program carried out
pursuant to section 2821. The Secretary may, upon the request
of the State, provide supplies and services in lieu of cash
payments.
Section 2829 requires the Secretary report to the
appropriate committees of Congress on the activities of the
States carried out pursuant to section 2821.
Section 2829 authorizes there to be appropriated to carry
out this part, $50 million for fiscal year 2002, $75 million
for fiscal year 2003, $75 million for fiscal year 2004, $100
million for fiscal year 2005, and $125 million for fiscal year
2006.
Section 2831 allows the Secretary to make grants to public
and non-profit private entities for the development and
implementation of education programs for appropriate health
professionals and students in the use of newly developed
diagnostic approaches, technologies, and therapies for the
prevention and treatment of stroke.
Section 2841 defines the following terms in the following
manner. (1) The term ``State'' means each of the several
States, the District of Columbia, the Commonwealth of Puerto
Rico, the Indian tribes, the Virgin Islands, Guam, American
Samoa, and the Commonwealth of the Northern Mariana Islands.
(2) The term ``stroke care system'' means a statewide system to
provide for the diagnosis, prehospital care, hospital
definitive care, and rehabilitation of stroke patients. (3) The
term ``stroke'' means a ``brain attack'' in which blood flow to
the brain is interrupted or in which a blood vessel or aneurysm
in the brain breaks or ruptures.
Section 2842 requires the Secretary to consult widely in
implementing the provisions of the Act.

IX. ADDITIONAL VIEWS OF MR. FRIST

As the lead Republican cosponsor of the S. 1274, the Stroke
Treatment and Ongoing Prevention Act of 2001, I am concerned
about some of the wording of the current report. Although I
fully support the overall goal of this Act to improve the
provision of stroke care across the nation and to increase
public awareness about the prevention, detection, and treatment
of stroke, I believe that the grants established in section
2831 should target those areas defined as having special
consideration (section 2827). All of the other programs
outlined within the Act--the medical professional development
grants, the stroke prevention and education campaign, and the
Paul Coverdell National Acute Stroke Registry and
Clearinghouse--will assist with the improvement of stroke care
nationwide.
The areas considered to have special consideration under
the Act are those geographic areas in which there is a
substantial incidence of stroke or a substantial rate of
disability resulting from stroke or areas that demonstrate a
significant need for assistance in developing a comprehensive
stroke care system. As we are all aware, twelve contiguous
states--Alabama, Arkansas, Florida, Georgia, Indiana, Kentucky,
Louisiana, Mississippi, North Carolina, South Carolina,
Tennessee, Virginia, and Washington, DC--form the ``Stroke
Belt'', an area with stroke death rates that are consistently
more than ten percent higher than the rest of the country.
Those areas with the greatest need should be our focus as we
work to increase stroke prevention and treatment programs
nationwide. Without this targeted intervention, we will not be
able to assist those areas in greatest need.

Bill Frist.

X. Changes in Existing Law

In compliance with rule XXVI paragraph 12 of the Standing
Rules of the Senate, the following provides a print of the
statute or the part or section thereof to be amended or
replaced (existing law proposed to be omitted is enclosed in
black brackets, new matter is printed in italic, existing law
in which no change is proposed is shown in roman):

PUBLIC HEALTH SERVICE ACT

* * * * * * *

TITLE XXVII--REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE

PART A--GROUP MARKET REFORMS

Subpart 1--Portability, Access, and Renewability Requirements

SEC. 2701. [300GG] INCREASED PORTABILITY THROUGH LIMITATION ON
PREEXISTING CONDITION EXCLUSIONS.

* * * * * * *

TITLE XXVIII--SYSTEMS FOR STROKE PREVENTION, TREATMENT, AND
REHABILITATION

PART A--STROKE PREVENTION AND EDUCATION CAMPAIGN

SEC. 2801. STROKE PREVENTION AND EDUCATION CAMPAIGN.

(a) In General.--The Secretary shall carry out a national
education and information campaign to promote stroke prevention
and increase the number of stroke patients who seek immediate
treatment. In implementing such education and information
campaign, the Secretary shall avoid duplicating existing stroke
education efforts by other Federal Government agencies and may
consult with national and local associations that are dedicated
to increasing the public awareness of stroke, consumers of
stroke awareness products, and providers of stroke care.
(b) Use of Funds.--The Secretary may use amounts
appropriated to carry out the campaign described in subsection
(a)--
(1) to make public service announcements about the
warning signs of stroke and the importance of treating
stroke as a medical emergency;
(2) to provide education regarding ways to prevent
stroke and the effectiveness of stroke treatment;
(3) to purchase media time and space;
(4) to pay for out-of-pocket advertising production
costs;
(5) to test and evaluate advertising and educational
materials for effectiveness, especially among groups at
high risk for stroke, including women, older adults,
and African-Americans;
(6) to develop alternative campaigns that are
targeted to unique communities, including rural and
urban communities, and communities in the ``Stroke
Belt'';
(7) to measure public awareness prior to the start of
the campaign on a national level and in targeted
communities to provide baseline data that will be used
to evaluate the effectiveness of the public awareness
efforts; and
(8) to carry out other activities that the Secretary
determines will promote prevention practices among the
general public and increase the number of stroke
patients who seek immediate care.
(c) Authorization of Appropriations.--There is authorized
to be appropriated to carry out subsection (b), $40,000,000 for
fiscal year 2002, and such sums as may be necessary for each of
fiscal years 2003 through 2006.

PART B--GENERAL AUTHORITIES AND DUTIES OF THE SECRETARY

SEC. 2811. ESTABLISHMENT.

(a) In General.--The Secretary shall, with respect to
stroke care--
(1) make available, support, and evaluate a grant
program to enable a State to develop statewide stroke
care systems;
(2) foster the development of appropriate, modern
systems of stroke care through the sharing of
information among agencies and individuals involved in
the study and provision of such care; and
(3) provide to State and local agencies technical
assistance.
(b) Grants, Cooperative Agreements, and Contracts.--The
Secretary may make grants, and enter into cooperative
agreements and contracts, for the purpose of carrying out
subsection (a).

SEC. 2812. PAUL COVERDELL NATIONAL ACUTE STROKE REGISTRY AND
CLEARINGHOUSE.

(a) In General.--The Secretary shall maintain the Paul
Coverdell National Acute Stroke Registry and Clearinghouse by--
(1) continuing to develop and collect specific data
points as well as appropriate benchmarks for analyzing
care of acute stroke patients;
(2) continuing to design and pilot test prototypes
that will measure the delivery of care to patients with
acute stroke in order to provide real-time data and
analysis to reduce death and disability from stroke and
improve the quality of life for acute stroke survivors;
(3) fostering the development of effective, modern
stroke care systems (including the development of
policies related to emergency services systems) through
the sharing of information among agencies and
individuals involved in planning, furnishing, and
studying such systems;
(4) collecting, compiling, and disseminating
information on the achievements of, and problems
experienced by, State and local agencies and private
entities in developing and implementing stroke care
systems and, in carrying out this paragraph, giving
special consideration to the unique needs of
ruralfacilities and those facilities with inadequate resources for
providing quality prevention, acute treatment, post-acute treatment,
and rehabilitation services for stroke patients;
(5) providing technical assistance relating to stroke
care systems to State and local agencies; and
(6) carrying out any other activities the Secretary
determines to be useful to fulfill the purposes of the
Paul Coverdell National Acute Stroke Registry and
Clearinghouse.
(b) Research on Stroke.--The Secretary shall, not earlier
than 1 year after the date of enactment of the Stroke Treatment
and Ongoing Prevention Act of 2001, ensure the availability of
published research on stroke or, where necessary, conduct
research concerning--
(1) best practices in the prevention, diagnosis,
treatment, and rehabilitation of stroke;
(2) barriers to access to currently approved stroke
prevention, treatment, and rehabilitation services;
(3) barriers to access to newly developed diagnostic
approaches, technologies, and therapies for stroke
patients;
(4) the effectiveness of existing public awareness
campaigns regarding stroke; and
(5) disparities in the prevention, diagnosis,
treatment, and rehabilitation of stroke among different
populations.
(c) Certain Research Activities.--In carrying out the
activities described in subsection (b), the Secretary may
conduct--
(1) studies with respect to all phases of stroke
care, including prehospital, acute, post-acute and
rehabilitation care;
(2) studies with respect to patient access to
currently approved and newly developed stroke
prevention and treatment services, including a review
of the effect of coverage, coding, and reimbursement
practices on access;
(3) studies with respect to the effect of existing
public awareness campaigns on stroke; and
(4) any other studies that the Secretary determines
are necessary or useful to conduct a thorough and
effective research program regarding stroke.
(d) Mechanisms of Support.--In carrying out the activities
described in subsection (b), the Secretary may make grants to
public and private non-profit entities.
(e) Coordination of Effort.--The Secretary shall ensure the
adequate coordination of the activities carried out under this
section.
(f) Authorization of Appropriations.--There is authorized to
be appropriated such sums as may be necessary for each of
fiscal years 2002 through 2006 to carry out this section.

PART C--GRANTS WITH RESPECT TO STATE STROKE CARE SYSTEMS

SEC. 2821. ESTABLISHMENT OF PROGRAM FOR IMPROVING STROKE CARE.

(a) Grants.--The Secretary shall award grants to States for
the purpose of establishing statewide stroke prevention,
treatment, and rehabilitation systems.
(b) Use of Funds.--
(1) In general.--The Secretary shall make available
grants under subsection (a) for the development and
implementation of statewide stroke care systems that
provide stroke prevention services and quality acute,
post-acute, and rehabilitation care for stroke patients
through the development of sufficient resources and
infrastructure, including personnel with appropriate
training, acute stroke teams, equipment, and procedures
necessary to prevent stroke and to treat and
rehabilitate stroke patients. In developing and
implementing statewide stroke care systems, each State
that is awarded such a grant shall--
(A) oversee the design and implementation of
the statewide stroke care system;
(B) enhance, develop, and implement model
curricula for training emergency medical
services personnel, including dispatchers,
first responders, emergency medical
technicians, and paramedics in the
identification, assessment, stabilization, and
prehospital treatment of stroke patients;
(C) ensure that stroke patients in the State
have access to quality care that is consistent
with the standards established by the Secretary
under section 2823(c);
(D) establish a support network to provide
assistance to facilities with smaller
populations of stroke patients or less advanced
on-site stroke treatment resources; and
(E) carry out any other activities that the
State-designated agency determines are useful
or necessary for the implementation of the
statewide stroke care system.
(2) Access to care.--A State may meet the requirement
of paragraph (1)(C) by--
(A) identifying acute stroke centers with
personnel, equipment, and procedures adequateto
provide quality treatment to patients in the acute phase of stroke
consistent with the standards established by the Secretary under
section 2823(c);
(B) identifying comprehensive stroke centers
with advanced personnel, equipment, and
procedures to prevent stroke and to treat
stroke patients in the acute and post-acute
phases of stroke and to provide assistance to
area facilities with less advanced stroke
treatment resources;
(C) identifying stroke rehabilitation centers
with personnel, equipment, and procedures to
provide quality rehabilitative care to stroke
patients consistent with the standards
established by the Secretary under section
2823(c); or
(D) carrying out any other activities that
the designated State agency determines are
necessary or useful.
(3) Support network.--A facility that provides care
to stroke patients and that receives support through a
support network established under paragraph (1)(D)
shall meet the standards and requirements outlined by
the State application under paragraph (2) of section
2823(b). The support network may include--
(A) the use of telehealth technology
connecting facilities described in such
paragraph to more advanced stroke care
facilities;
(B) the provision of neuroimaging, lab, and
any other equipment necessary to facilitate the
establishment of a telehealth network;
(C) the use of phone consultation, where
useful;
(D) the use of referral links when a patient
needs more advanced care than is available at
the facility providing initial care; and
(E) any other assistance determined
appropriate by the State.
(c) Planning Grants.--
(1) In general.--The Secretary may award a grant to a
State to assist such State in formulating a plan to
develop a statewide stroke care system or in otherwise
meeting the conditions described in subsection (b) with
respect to a grant under this section.
(2) Submission to secretary.--The governor of a State
that receives a grant under paragraph (1) shall submit
to the Secretary a copy of the plan developed using the
amounts provided under such grant. Such plan shall be
submitted to the Secretary as soon as practicable after
the plan has been developed.
(3) Single grant limitation.--To be eligible to
receive a grant under paragraph (1), a State shall not
have previously received a grant under such paragraph.
(d) Model Curriculum.--
(1) Development.--The Secretary shall develop a model
curriculum for training emergency medical services
personnel, including dispatchers, first responders,
emergency medical technicians, and paramedics in the
identification, assessment, stabilization, and
prehospital treatment of stroke patients.
(2) Implementation.--The model curriculum developed
under paragraph (1) may be implemented by a State to
fulfill the requirements of subsection (b)(1)(B).

SEC. 2822. REQUIREMENT OF MATCHING FUNDS FOR FISCAL YEARS SUBSEQUENT TO
FIRST FISCAL YEAR OF PAYMENTS.

(a) Non-Federal Contributions.--
(1) In general.--The Secretary may not award grants
under section 2821(a) unless the State involved agrees,
with respect to the costs described in paragraph (2),
to make available for each year during which the State
receives funding under such section, non-Federal
contributions (in cash or in kind under subsection
(b)(1)) toward such costs in an amount equal to--
(A) for the second and third fiscal years of
such payments to the State, not less than $1
for each $3 of Federal funds provided in such
payments for each such fiscal year;
(B) for the fourth fiscal year of such
payments to the State, not less than $1 for
each $2 of Federal funds provided in such
payments for such fiscal year; and
(C) for any subsequent fiscal year of such
payments to the State, not less than $1 for
each $1 of Federal funds provided in such
payments for such fiscal year.
(2) Program costs.--The costs referred to in
paragraph (1) are the costs to be incurred by the State
in carrying out the purpose described in section
2821(b).
(3) Initial year of payments.--The Secretary may not
require a State to make non-Federal contributions as a
condition of receiving payments under section 2821(a)
for the first fiscal year of such payments to the
State.
(b) Determination of Amount of Non-Federal Contributions.--
With respect to compliance under subsection (a) as a condition
of receiving payments under section 2811(a)--
(1) a State may make the non-Federal contributions
required in such subsection in cash or in kind, fairly
evaluated, including plant, equipment, or services; and
(2) the Secretary may not, in making a determination
of the amount of non-Federal contributions, include
amounts provided by the Federal Government or services
assisted or subsidized by a significant extent by the
Federal Government.

SEC. 2823. APPLICATION REQUIREMENTS.

(a) Requirement of Application.--The Secretary may not award
a grant to a State under section 2821(b) unless an application
for the grant is submitted by the State to the Secretary.
(b) Application Process and Guidelines.--The Secretary shall
provide for an application process and develop guidelines to
assist States in submitting an application under this section
that--
(1) outlines the stroke care system and explains how
such system will ensure that stroke patients throughout
the State have access to quality care in all phases of
stroke, consistent with the standards established by
the Secretary under subsection (c);
(2) contains standards and requirements for
facilities in the State that provide basic preventive
services, advanced preventive services, acute stroke
care, post-acute stroke care, and rehabilitation
services to stroke patients; and
(3) provides for the establishment of a central data
reporting and analysis system and for the collection of
data from each facility that will provide direct care
to stroke patients in the State--
(A) to identify the number of stroke patients
treated in the State;
(B) to monitor patient care in the State for
stroke patients at all phases of stroke for the
purpose of evaluating the diagnosis, treatment,
and treatment outcome of such stroke patients;
(C) to identify the total amount of
uncompensated and under-compensated stroke care
expenditures for each fiscal year by each
stroke care facility in the State;
(D) to identify the number of acute stroke
patients who receive advanced drug therapy;
(E) to identify patients transferred within
the statewide stroke care system, including
reasons for such transfer; and
(F) to communicate to the greatest extent
practicable with the Paul Coverdell National
Acute Stroke Registry and Clearinghouse.
(c) Certain Standards With Respect to Statewide Stroke Care
System.--
(1) In general.--The Secretary may not award a grant
to a State under section 2821(a) for a fiscal year
unless the State agrees that, in carrying out
paragraphs (2) and (3), the State will--
(A) adopt standards of care for stroke
patients in the acute, post-acute, and
rehabilitation phases of stroke; and
(B) in adopting the standards described in
subparagraph (A)--
(i) consult with medical, surgical,
and nursing specialty groups, hospital
associations, voluntary health
organizations, State offices of rural
health, emergency medical services
State and local directors, experts in
the use of telecommunications
technology to provide stroke care,
concerned advocates, and other
interested parties;
(ii) conduct hearings on the proposed
standards providing adequate notice to
the public concerning such hearing; and
(iii) beginning in fiscal year 2004,
take into account the national
standards of care.
(2) Quality of stroke care.--The highest quality of
stroke care shall be the primary goal of the State
standards adopted under this subsection.
(3) Approval by secretary.--The Secretary may not
make payments to a State under section 2821(a) if the
Secretary determines that--
(A) the State has not taken into account
national standards in adopting standards under
this subsection;
(B) in the case of payments for fiscal year
2004 and subsequent fiscal years, the State has
not, in adopting such standards, taken into
account the national standards of care and the
model system plan developed under subsection
(c); or
(C) in the case of payments for fiscal year
2004 and subsequent fiscal years, the State has
not provided to the Secretary the information
received by the State pursuant to paragraphs
(9) and (10) of subsection (a).
(d) Model Stroke Care System Plan.--Not later than 1 year
after the date of enactment of the Stroke Treatment and Ongoing
Prevention Act of 2001, the Secretary shall develop standards
of care for stroke patients in all phases of stroke that may be
adopted for guidance by the State and a model plan for the
establishment of statewide stroke care systems. Such plan
shall--
(1) take into account national standards;
(2) take into account existing State systems and
plans; and
(3) take into account the unique needs of urban and
rural communities, different regions of the Nation, and
States with varying degrees of established stroke care
infrastructures;

SEC. 2824. REQUIREMENT OF SUBMISSION OF APPLICATION CONTAINING CERTAIN
AGREEMENTS AND ASSURANCES.

The Secretary may not award grants under section 2821(a) to
a State for a fiscal year unless--
(1) the State submits an application for the payments
containing agreements in accordance with this part;
(2) the agreements are made through certification
from the chief executive officer of the State;
(3) with respect to such agreements, the application
provides assurances of compliance satisfactory to the
Secretary;
(4) the application contains the plan provisions and
the information required to be submitted to the
Secretary pursuant to section 2823; and
(5) the application otherwise 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 part.

SEC. 2825. RESTRICTIONS ON USE OF PAYMENTS.

(a) In General.--The Secretary may not, except as provided
in subsection (b), make payments to a State under section
2821(a) for a fiscal year unless the State involved agrees that
the payments will not be expended--
(1) to make cash payments to intended recipients of
services provided pursuant to such section;
(2) to satisfy any requirement for the expenditure of
non-Federal funds as a condition for the receipt of
Federal funds; or
(3) to provide financial assistance to any entity
other than a public or nonprofit private entity.
(b) Exception.--If the Secretary finds that the purpose
described in section 2821(b) cannot otherwise be carried out,
the Secretary may, with respect to an otherwise qualified
State, waive the restriction established in subsection (a)(3).

SEC. 2826. FAILURE TO COMPLY WITH AGREEMENTS.

(a) Repayment of Payments.--
(1) Requirement.--The Secretary may, in accordance
with subsection (b), require a State to repay any
payments received by the State pursuant to section
2821(a) that the Secretary determines were not expended
by the State in accordance with the agreements required
to be made by the State as a condition of the receipt
of payments under such section.
(2) Offset of amounts.--If a State fails to make a
repayment required in paragraph (1), the Secretary may
offset the amount of the repayment against any amount
due to be paid to the State under section 2821(a).
(b) Opportunity for a Hearing.--Before requiring repayment
of payments under subsection (a)(1), the Secretary shall
provide to the State an opportunity for a hearing.

SEC. 2827. SPECIAL CONSIDERATION.

In awarding grants under this part, the Secretary shall
give special consideration to any State that has submitted an
application for carrying out programs under such a grant--
(1) in geographic areas in which there is--
(A) a substantial rate of disability
resulting from stroke; or
(B) a substantial incidence of stroke; or
(2) that demonstrates a significant need for
assistance in establishing a comprehensive stroke care
system.

SEC. 2828. TECHNICAL ASSISTANCE AND PROVISION BY SECRETARY OF SUPPLIES
AND SERVICES IN LIEU OF GRANT FUNDS.

(a) Technical Assistance.--The Secretary shall, without
charge to a State receiving payments under section 2821(a),
provide to the State (or to any public or nonprofit entity
designated by the State) technical assistancewith respect to
the planning, development, and operation of any program carried out
pursuant to section 2821(b). The Secretary may provide such technical
assistance directly, through contract, or through grants.
(b) Provisions by Secretary of Supplies and Services in
Lieu of Grant Funds.--
(1) In General.--Upon the request of a State
receiving payments under section 2821(a), the Secretary
may, subject to paragraph (2), provide supplies,
equipment, and services for the purpose of aiding the
State in carrying out section 2821(b) and, for such
purpose, may detail to the State any officer or
employee of the Department of Health and Human
Services.
(2) Reduction in Payments.--With respect to a request
described in paragraph (1), the Secretary shall reduce
the amount of payments to the State under section
2821(a) by an amount equal to the costs of detailing
personnel and the fair market value of any supplies,
equipment, or services provided by the Secretary. The
Secretary shall, for the payment of expenses incurred
in complying with such request, expend the amounts
withheld.

SEC. 2829. REPORT BY SECRETARY.

Not later than 3 years after the date of enactment of the
Stroke Treatment and Ongoing Prevention Act of 2001, the
Secretary shall report to the appropriate committees of
Congress on the activities of the States carried out pursuant
to section 2821. Such report shall include an assessment of the
extent to which Federal and State efforts to develop stroke
care systems, including the establishment of support networks
and the identification of acute, comprehensive, and
rehabilitation stroke centers, where applicable, have increased
the number of stroke patients who have received acute stroke
consultation or therapy within the appropriate timeframe and
reduced the level of disability due to stroke. Such report may
include any recommendations of the Secretary for appropriate
administrative and legislative initiatives with respect to
stroke care.

SEC. 2830. FUNDING.

(a) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this part, $50,000,000 for
fiscal year 2002, $75,000,000 for fiscal year 2003, $75,000,000
for fiscal year 2004, $100,000,000 for fiscal year 2005, and
$125,000,000 for fiscal year 2006.
(b) Limitation on Administrative Expenses.--A State may use
not to exceed 10 percent of amounts received under a grant
awarded under section 2821(a) for administrative expenses.

PART D--MISCELLANEOUS PROGRAMS

SEC. 2831. MEDICAL PROFESSIONAL DEVELOPMENT IN ADVANCED STROKE
TREATMENT AND PREVENTION.

(a) In General.--The Secretary may make grants to public
and non-profit private entities for the development and
implementation of education programs for appropriate medical
personnel including medical students, emergency physicians,
primary care providers, neurologists, neurosurgeons, and
physical therapists in the use of newly developed diagnostic
approaches, technologies, and therapies for the prevention and
treatment of stroke.
(b) Distribution of Grants.--In awarding grants under
subsection (a), the Secretary shall ensure that such grants are
equitably distributed among the geographical regions of the
United States and between urban and rural populations.
(c) Application.--A public or non-profit private entity
desiring a grant under subsection (a) 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 a plan for the rigorous evaluation of activities
carried out with amounts received under such a grant.
(d) Use of Funds.--A public or non-profit private entity
shall use amounts received under a grant under this section for
the continuing education of appropriate medical personnel in
the use of newly developed diagnostic approaches, technologies,
and therapies for the prevention and treatment of stroke.
(e) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section, such sums as may
be necessary for each of fiscal years 2002 through 2006.

PART E--GENERAL PROVISIONS REGARDING PARTS A, B, C, and D

SEC. 2841. DEFINITIONS.

In this title:
(1) State.--The term ``State'' means each of the
several States, the District of Columbia, the
Commonwealth of Puerto Rico, the Indian tribes, the
Virgin Islands, Guam, American Samoa, and the
Commonwealth of the Northern Mariana Islands.
(2) Stroke Care System.--The term ``stroke care
system'' means a statewide system to provide for the
diagnosis, prehospital care, hospital definitive care,
and rehabilitation of stroke patients.
(3) Stroke.--The term ``stroke'' means a ``brain
attack'' in which blood flow to the brain is
interrupted or in which a blood vessel or aneurysm in
the brain breaks or ruptures.

SEC. 2842. CONSULTATIONS.

In carrying out this title, the Secretary shall consult
with medical, surgical, rehabilitation, and nursing specialty
groups, hospital associations, voluntary health organizations,
emergency medical services, State directors, and associations,
experts in the use of telecommunication technology to provide
stroke care, national disability and consumer organizations
representing individuals with disabilities and chronic
illnesses, concerned advocates, and other interested parties.

* * * * * * *